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This text is an extract from Neurovetenskaplig psykiatri. Copyright © 2018 Christoffer Rahm och Natur & Kultur.
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Part III: Psychopathology
Psychopathology is a complicated subject. On the philosophic level we need to consider a
number of fundamental questions, which can all be answered in different ways depending on
the perspective and outlook. What is mental illness? Does mental illness even exist? In that
case, where is the boundary between sick and healthy? Between mental illness and non-
mental illness? Are there different groups of mental illness? What is the cause of mental
illness?
There have been different interpretations of behaviour located on the outskirts of
normality and the conditions treated within psychiatry, depending on the culture and school of
thought. Interpretations range from punishment of the individual by the gods, special
selection, witchcraft or inborn moral defects. Among these ideas there is also a long tradition,
established during the times of Hippocrates, Aristotle and Galen, of understanding and
explaining mental illness using medical models – weak nerves, energy disturbances in bodily
organs or imbalance in bodily fluids. Although these specific theories have been abandoned
over time, the medical approach in which mental illness has a bodily cause has grown
stronger within psychiatry and is currently the dominant outlook.
What mental illness is and whether or not it even exists depend of course on how we define
the terms. The word “psyche” comes from the Greek word for soul or, from a more modern
perspective, consciousness. The term has sometimes referred to a more immaterial, spiritual
aspect of humanity however, as described in the first part of the book, the basis of this book is
that the activities of the psyche or consciousness are the result of brain activity. Psyche is thus
used here as a collective term for the processes in the body and especially the brain that give
rise to thought, feeling, social ability and personality.
The term “disease”. As used in modern Western medicine, the term is based on the
principle that disease involves delimited processes and conditions which differ from healthy
conditions by causing premature death, pain, functional impairment or other problems. The
conditions may also involve a decreased ability to live with others and have children, or an
increased tendency to develop another disease. According to the biomedical tradition, disease
is thought to develop through delimited interactions between individuals and their genes
and/or environment. These mechanical causal links are considered to drive disease
development.
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The biomedical disease paradigm.
The answer to the first of the questions (“What is mental illness?”) lies therefore in the
basis of this book. Here, mental illness refers to biomedical conditions that affect the
functions, originating primarily in the brain, which include thought, emotion, social
interaction and personality.
Using this definition, the next question can be answered with a counterquestion, namely:
Can structures such as the association cortex, limbic system, brainstem and basal ganglia be
affected by disease states in the same way as the rest of the body? The answer is: Yes. We
will see that it has been established that nearly all the classical pathological processes that
affect the rest of the body can also be found in the brain (genetic and epigenetic disease
processes, metabolic and inflammatory processes, toxicity, stress, infection, autoimmunity,
lesions, tumours, deposition, etc.) as well as some additional processes that are characteristic
of the central nervous system (such as the failure of neural networks, epilepsy and
excitotoxicity). Conversely, for the vast majority of mental disorders and diagnoses, signs of
such disease processes in the brain have been found (in psychotic disorder, bipolar spectrum
disorder, autism spectrum disorders, anxiety disorder, eating disorders, ADHD and many
others). Mental illness does exist.
This does not imply that all patients with a psychiatric diagnosis have a mental illness in
the biomedical sense, or even that there is a diagnosis for every disease process. That is not
how the diagnostic system works in psychiatry. A diagnosis is not made based on the
pathophysiological processes. Psychiatry does not have, for example, one group of
autoimmune diseases, one group of inflammatory diseases and one group of metabolic
diseases in the way that internal medicine does.
Instead, the tradition within psychiatry is that the diagnosis is based on the clinical
presentation, similar to the method used in the early history of classical medicine. Diagnosis
in psychiatry is therefore not concerned with aetiology (the cause of the disease) or
pathophysiology (function of the organism while in a disease state), but on the symptoms and
disease progression (the clinical manifestation). This is one reason why the term “disease” is
not used in psychiatric diagnoses; instead, the terms “disorder” or “syndrome” are used.
According to the definition in diagnosis manuals, depression is therefore not referred to as a
disease state but as a disorder or syndrome, as are schizophrenia, ADHD, anorexia nervosa
and all other conditions described.
In this book I have chosen to use the term “disorder” because the meaning of the term
“syndrome” can be easily Although disorder has a somewhat negative ring to it, it has the
advantage that it permits the consideration of other, alternative underlying mechanisms than
the pathophysiological. For example, it does not exclude the possibility that the “symptoms”
are in fact normal variations of behaviour or that the disease course basically reflects a healthy
response to difficult circumstances.
Other terms are used and syndrome, for example the neutral term “condition” is often
used . As an aside, it can be mentioned that the word “disease” is included in many terms
used in psychiatry: “disease debut”, “disease course”, “disease group”, etc.
Regarding the line between mental health and mental illness, there is no clear and
unambiguous answer. Partly for the same reasons – it depends on which meaning of the word
mental illness (or disorder) you are using. If you refer to the more classical, biomedical
meaning, then there is a description of the difference between healthy and ill which I gave in
brief above. However if you are referring to mental “disorder”, the major psychiatric
diagnosis manuals use a different rule of thumb, albeit with many exceptions. This means
that, in addition to typical symptoms and a typical disease course, the presence of “clinically
significant suffering” or “functional impairment” is also required. These terms are in the
majority of the criteria lists for each diagnosis in the manuals.
This aspect makes it difficult to answer the question, as the experience of clinically
significant suffering and functional impairment varies depending on the individual and the
environment. The same problems may entail suffering or functional impairment in one
individual but not another. Also, a condition that would cause an individual suffering and
functional impairment may not have the same consequences if the same individual was placed
in a different environment. It is therefore often difficult to define the line between mental
health and mental disorder. It may be difficult, for example, to determine when it is a matter
of “only” grief, and when it should be classified instead as depression.
The solution to this problem is staring us in the face. As a psychiatrist, if you consistently
use the words “disease” and “disorder” in the contexts in which they are intended to be used,
you can avoid many problems with the definitions. The purpose of the diagnostic manuals is
to guide diagnosis by the establishment of criteria lists of what should be present for one or
other of the terms to be used. Their purpose is not to describe the actual essence of the mental
illness and which underlying mechanisms bring about the different symptoms of illness. The
term disorder can thus be used in contexts where you need to characterise and diagnose the
situation of different patients, the clinical, symptomatic and progressive manifestation, but
you can also feel secure using the word disease when discussing how the underlying biology
of brain functions may be negatively affected and lead to symptoms.
Now that we have said something about mental disorder/illness, we also have the tools to
answer the following questions; where is the boundary between mental illness and non-mental
illness? Are there different groups of mental illness?
Historically, several of the disorders that were first thought to be psychological ceased to
be regarded as such once a clear biological explanation for them was found. Epilepsy, for
example, underwent such development, as have various genetic syndromes, various types of
stroke, some neurological development disorders, neurosyphilis and several metabolic
disorders. These are no longer classified as mental illness in the manuals. Instead they are
seen as diseases of the body and are managed by other specialties. This seems to be changing
to some extent, with less zeal exercised with regards to the automatic exclusion from
psychiatric diagnosis manuals as soon as a “bodily” cause has been found for the “mental”
symptoms of any particular diagnosis. This may be related to the changing perspective on the
psyche and a strengthened understanding of the biological substrate. For example, dementias
are still classified as mental disorders, even though convincing biological markers have been
found for most types. Several quite unusual genetic syndromes, including autism spectrum
disorders, are also listed as mental disorders, even though their genetic backgrounds are now
known. Traces of the old principles can still be seen. For example, Rett syndrome was
excluded in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM, the American Psychiatric Association’s diagnosis manual, which is used in many
countries, including Sweden) because an underlying genetic cause of the condition was found
since the publication of the previous edition.
The boundaries are somewhat fluid with regards to classification into different disorders.
If we examine them closely we find that the disorders overlap on several levels, more than
might have been expected if we had been discussing discrete disease entities. For example,
they overlap at symptom level – the same types of symptoms are found in several disorders; at
treatment level – the same treatments help against several disorders; and at the biological
level – the same environmental exposure factors, brain regions and genes are involved in
several disorders. Comorbidity is also high between different groups of disorders. We talk
increasingly about clusters of disorders, or spectra, within which we accept such overlaps.
Regarding the classification of mental disorders, the answer is that we can simply look at one
of the major diagnostic manuals to see which groups of mental disorders are considered to
exist, and be prepared for that list to change from edition to edition, depending on which
experts are asked and their opinions.
On the other hand, the questions are more difficult to answer and less relevant, with
regards to the boundary between mental and non-mental illness, and the classification of
different mental illnesses. In this book I have focused on cognition, emotion, personality and
social ability, using psyche as an umbrella term for these, and allowed the disease processes
that negatively affect these particular functions to form the psychopathological boundary. The
groups of disease processes I am discussing are based on categorisation at the
pathophysiological level, according to the same classification as that used in the initial
sections on healthy function in this book.
In summary, it is now primarily a question of tradition and creativity when defining the
boundary between mental and non-mental illness, respectively, and how to classify mental
disorder/illness into different groups. We will discuss this in more depth in the next part of the
book, and note that although the classification system used in the major diagnostic manuals
may currently be the best possible system, the field is making little progress while awaiting a
new disease classification system (nosology) in psychiatry, perhaps more based on biomedical
principles. Diagnostics has already undergone this development in several other medical
specialties.
Finally, what causes mental disorders? Among the many theories there are three larger groups
of views that have most often been asserted, sometimes in conflict with each other:
1. The psychological theories. Some are more psychodynamic: that psychological

issues should be understood in the light of unresolved inner conflicts that have
arisen during the individual’s childhood, or more existential issues. Some are more
behavioural: that symptoms arise because they have a function, they help the
individual to avoid anxiety and discomfort, albeit temporarily, for example a
patient with compulsive thoughts of feeling unclean experiences anxiety and
therefore attempts to counteract this by repeated washing. Or because they are
caused by incorrect learning, for example an adult individual may react
aggressively in conflict situations because that was the way their parents acted
during their childhood.
2. The sociological theories. These are based on the idea that unhealthy structures in
families or society create or evoke symptoms. This may refer to gender roles,
social group affiliation or norms – requirements from the surroundings to be in a
certain way.
3. The more biologically-based theories, where the primary interests are the
biomedical processes.
Neuroscientific psychiatry has established a kind of integration of these perspectives, but has
its basis in the biological processes. The basis of neuroscientific psychiatry, as in this book, is
that most mental disorders, as well as the resilience against them, seem to arise as a result of
complex interactions between hereditary and environmental factors. Furthermore, traumatic
childhood events, incorrect learning, societal structures and pathophysiological processes play
a role and must be taken into consideration when trying to understand the origin of a mental
disorder. In addition, the biological conditions and behaviours that may be a strength and
advantage in some environments may be a disadvantage in others. The reader will also notice
that psychiatry includes few disease states for which it has been possible to map out the
underlying mechanisms in detail. The presence of one or more models for their genesis is
much more common. This is independent of the basic outlook.
To my knowledge, this book is one of the few attempts to write a general and comprehensive
psychiatric pathology based on a neuroscience perspective. I decided to use an structure
where this part of the book discusses the same topics as in the first part of the book, but now
has a psychopathological perspective. This means that I first look at how genes, the
surrounding environment, upbringing and life events can affect and lead to mental disorder. A
section on the genetic mechanisms follows. The following section, which constitutes the main
section, examines the role of the brain in the genesis of mental disorder. Finally, we look at
different models of resilience to mental disorder. The description of the brain’s functional
domains and personality has no corresponding material in this section; this is found in Part IV
(under “Psychiatric status”). In my opinion, in the same way as the work of a healthy mind is
expressed in thoughts and emotions, psychiatric symptoms are to be understood as affecting
these processes – possibly due to stress, trauma, a pathophysiological process, a response to
the disease state itself, or another underlying cause.
This part of the book may be experienced as more difficult to understand than the first
part. This is partly due to the fact that the components that make up the brain and contribute to
healthy function fit so well together, and can so easily become part of a story about a larger
and more well-adapted entity – human behaviour. In contrast, the processes that lead to
mental disorder appear to be much more random and unrelated to each other; they do not
seem to interact to work towards a common goal and must therefore be examined
individually.
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This text is an extract from Neurovetenskaplig psykiatri. Copyright © 2018 Christoffer Rahm och Natur & Kultur.

<Image J, half page>

The biomedical disease paradigm.

1. The psychological theories. Some are more psychodynamic: that psychological

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