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OUR IMPENETRABLE PERSONAL COMPUTER

Wanda was in her late thirties when I saw her for an admission evaluation on my hospital service. She was a bright and creative woman who made jewelry for a living, and had recently gone through a traumatic breakup with a rather domineering boyfriend of several years. This apparently led to the reemergence of depression with suicidal thoughts, after over fifteen years without any significant psychiatric complaints. She was prescribed a routine antidepressant medication, with the addition of a low dosage antipsychotic agent to control some mild auditory hallucinations. After a successful but otherwise unremarkable course of treatment, she was discharged to outpatient care with another psychiatrist. What was remarkable, however, was her past history. Wanda first entered psychiatric treatment at age 19, when she was hospitalized for depression after inflicting numerous lacerations on both her upper arms. For a year prior to this admission she had exhibited increasingly erratic behavior, with a chaotic and fringe lifestye that included a number of successive relationships, and several months of living on the streets in a college town in another state. She eventually returned home to live with her parentsa father who was emotionally stable and passively supportive, and a mother who was intrusive, immature, and a compulsive gambler. Wanda soon became depressed, and began hearing voices that criticized her and told her to cut herself. Over the next couple of years she was in and out of the psychiatric hospital for recurrent self-destructive urges, and was treated by a private psychiatrist who was on the clinical faculty of a nearby
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medical school. She was started on a combination of psychiatric medications that included tricyclic antidepressantsthe most popular class of antidepressants prior to the age of Prozac, with numerous troublesome side effects including weight gain, dizziness, dry mouth, and the risk of fatal overdosealong with antipsychotics, mood stabilizers, and tranquilizers. At her impressionable age she became strongly identified with idea of being a psychiatric patient, which was reinforced by the development of a close friendship with Liz, a woman in her mid-thirties who had been a patient for many years. Wanda and Liz often traded medications with each other, experimented by taking doses over and above that recommended by their shared psychiatrist, and frequently binged out together eating ice cream and other sweets. In the meantime Wandas mother doted on her, relishing the opportunity to have a dependent child at home for companionship. Her father was a kind and enabling sort, working steadily and providing support while avoiding any critical conflict with either Wanda or her mother. About the only person that asked anything at all of Wanda was her therapist, Chuck, who was working under the supervision of the psychiatrist. Wanda gained a lot of weight due to the medications and her poor lifestyle, and became increasingly isolated from her normal friends, with little social contact outside her parents, Liz, and Chuck. Wandas downhill spiral continued for months, with repeated episodes of cutting and other selfdestructive behaviors, multiple hospitalizations, and numerous medication trials using complex regimens of multiple agents. Chuck steadfastly maintained the belief that Wanda was redeemable, and was eventually able to persuade her that Liz was a destructive influence on her lifeand Wanda hesitantly agreed to distance herself. This prompted Liz to fly into a rage,
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cutting off all contact with Wanda. After a week Liz was found dead of a medication overdose. This tragedy had a peculiarly cathartic effect on Wanda. At the behest of Chuck she agreed to voluntary hospital admission as a precautionary measure, but had no suicidal urges whatsoever. After a brief stay she was discharged, and immediately decided to discontinue all of her psychiatric medications. Chuck was supportive, but urged Wanda to consult with the psychiatrist to be on the safe side. When she met with the doctor she announced that she was feeling much better off her medications, with no psychiatric symptoms whatsoever, and would like to continue off of them. The psychiatrist refused to support this decision, declaring that Youre masking your depression (whatever the hell that means) and recommending resumption of her medications. Wanda ignored him and never saw him again, but continued in therapy for some time afterward with Chuckwho diplomatically sidestepped any criticism of his boss direction. Wanda improved steadily, returning to college and moving on with her life, with no need for psychiatric intervention until her admission to my service many years later. It was not until my evaluation that Wanda finally revealed contributory history that was unknown to her previous providers. When she was sixteen and living at home, she had become involved in a sexual relationship with Jim, a young man in his twenties with a criminal history and sadistic tendencies. Over the course of several months together he began to incorporate pornography into their relationship, which subsequently led to bondage, and then more overtly sadistic activities. One night he bound her and without warning inserted a knife into her vagina, causing a significant
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laceration and profuse bleeding. Even though she was injured, distraught, and terrified, he refused to take her to the hospital for care, obviously fearing the legal consequences of his actions. He instead remained with her until the bleeding eventually stopped, and balefully instructed her to tell no one about the incident before he took her home. After this horrifying event Wanda decided to break off the relationship. However Jim wouldnt take no for an answer, and began to stalk and threaten her. At the time Wanda was attending a small non-denominational church where she had a close relationship with the pastor, who just happened to be an ex-biker. Wanda fortunately divulged the problems she was having with Jim to the pastor, who rounded up a couple of ex-biker friends and paid him a visit. They beat the hell out of Jim, and smashed the windshield of his car for good measurewhich evidently is a handy protocol for discouraging stalkers, since Jim was never heard from again. Thereafter Wanda suffered with recurrent nightmares in which she vividly relived the incident with the knife, from which she would awaken thrashing and screaming loudly. Only after many years did these nightmares gradually diminish in frequency and intensity. So what can we learn from this account? Well, certainly that the biological model of psychiatric care can be a recipe for hubrisbut thats not why Im sharing this story in this chapter. My goal here is to illustrate just how gloriously, and terrifyingly, complex the mind is. And also to convincingly demonstrate that in this business, one never knows what they dont know. When physicians try to conceptualize the function of a particular organ system, they often turn to mechanical models for help. As we all hopefully
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know, the heart is not really the seat of loveits a pump. It simultaneously propels two different channels of blood flowone to the peripheral body, and one to the lungseach of which has two valved chambers for reception and ejection of the blood. It has an internal electrical system to coordinate and regulate the activity of these component chambers. This system adjusts the heart rate and stroke volume to optimize its function in response to hormone levels, the autonomic nervous system, and intrinsic input from the heart itself. In short, it is a very smart, self-sufficient, and reliable pump, but nonetheless a pump. Hence when cardiologists study hemodynamics (the study of blood flow), they employ computational fluid dynamics that are similar to those used to predict the function of mechanical pumps. Patients in open-heart surgery typically require the use of a heart-lung machine to circulate and oxygenate the blood supply while the heart is out of commission. A pump is used to approximate the function of the heart, while an extracorporeal membrane oxygenator (ECMO) is used to perfuse the blood with oxygen, and remove carbon dioxide, before it is returned to the body. Not surprisingly, the term membrane oxygenator would be a pretty good description for a human lung. Likewise the kidney is a very smart filter that removes wastes but spares nutrients, and regulates the chemical balance of the blood supplyand hemodialysis utilizes a complex mechanical filter that approximates these functions for patients with renal failure. Applying the same logic to the brain, it doesnt take much sense to figure out that its appropriate mechanical counterpart is a computera machine that receives input, stores and processes data, and then provides useful output. All the components of a functioning computer can be classified as either hardware, which includes all the tangible mechanical components of
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the computeror as software, comprised of the programs, routines, and symbolic languages that control the functioning of the hardware and direct its operation. This divided architecture neatly mimics the complementary relationship of brain and mind. But when biological psychiatry entered the clinical mainstream in the late Seventies and early Eighties, the preferred metaphor for psychiatric illness was diabetes, which was habitually used to pitch medication therapy to a new generation of patients. On the face of it the analogy is ridiculous. Diabetes is caused either by inadequate production of insulin by the pancreas, or by the resistance of peripheral cells to the available insulin. To liken something as marvelously multifaceted as brain physiology to a dumb gland producing a single hormone was a throwback to 18th Century psychiatry neglecting not only all the accumulated medical knowledge gained since that era, but all logic as well. However as clinical propaganda it proved convenient and compelling, making patients feel like they understood both their illness and their need for medication. It created a desirable sense of medical urgency, since diabetes was well-known as a chemical imbalance that could lead to harm or even death. It also handily conveyed the belief that ones psychiatric illness just happens to you, with no implicit responsibility or shame, relieving the patient of the burden of stigmawhich was a much more acute problem in that day than it is now. And finally, it reinforced the perception that such disorders were chronic in nature, and likely to require the continuation of medication into the indefinite future. Even teenage patients (including Wanda) were often told that they would have to take medication for the rest
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of your lifean egregiously unsupportable claim, that can be most charitably explained as the presumption of a psychiatrist believing his own bullshit. Its safe to say that this metaphorical use of diabetes contributed significantly to the destigmatization of psychiatric illness and treatment, as the idea that depression and bipolar disorder are manifestations of a chemical imbalance eventually took root in our cultural psyche. But of course, the intervening decades have seen a huge reconsideration of the idea that diabetes just happens, as our understanding of the adult-onset (i.e. Type 2) form of the disease has grown. The national epidemic of diabetes mellitus has forced us to acknowledge the contribution of the typical American diet and lifestyle to its pathogenesis. Psychiatric care has ironically been implicated as well, since a number of popular medications (most of them antipsychotics) have been found to have significant diabetogenic effects, often accompanied by an alarming degree of weight gain. If you take this diabetes metaphor one step further, you might have to consider the possibility that psychiatric illnesses likewise dont just happen, and that other factors (including diet and lifestyle) might be contributory in a significant portion of the afflicted population. Fortunately for the psychiatric industry this idea has yet to catch on patients seem more willing than ever to accept the idea that they have a psychiatric disorder that has just happened, and to try a pill (or two or three) to resolve their unwanted feelings. Meanwhile the catalog of nominal psychiatric disorders continues to grow, with an explosion of diagnostic indications for medication intervention over the past decade. Strangely, you dont hear the diabetes metaphor used much anymoreits the inevitability of psychiatric disorders that now seems to be a given.
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On reflection, the indiscriminate name-dropping of diabetes to promote compliance with psychiatric medications was either naively foolish, or crassly manipulativeor, as I suspect, both at the same time. Psychiatry saw itself as standing on the threshold of a brave new world, with heady dreams of resolving complicated problems with a stroke of the penon a prescription pad, that isand in deference to our fickle tradition, we swallowed this new treatment model hook, line, and sinker. And even if we happened to know in our gut that the diabetes model was simplistic (to say the least)well, how were we possibly going to help our poor patients, if we couldnt convince them just how urgently they needed to take our wondrous medications? Our profession has yet to recover from this paternalistic delusion, clinging to this simplistic disease model without fully reckoning just how far off the mark weve gone. It seems likely to me that this failure to do what other specialties have doneto use the most analogous mechanical model as a point of reference, in order to better conceptualize our focal organ system was no accident, but a calculated evasion of the obvious. Because if you thoughtfully apply the computer model to what we know about brain physiology, it raises some serious questions about the potential benefits that can possibly be gained from medication intervention. First lets consider the brain as a piece of hardware. Surrounded by a sturdy case of bone, fibrous tissue, and fluid cushioning, it consists of an estimated one hundred billion neurons, each with thousands of shared synaptic interconnections, utilizing over 100 different chemical neurotransmitters. The total number of synapses in the brain ranges in the hundreds of trillions. In addition to the more obvious cognitive processes, the brain provides processing of all sensory data, and regulatory input to all the
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voluntary and involuntary processes required to maintain and operate the body. The architecture of this hardware system is not simply determined genetically, but modified throughout childhood development and into adulthood through the process of neuroplasticity. Research has established that learning occurs not just through neurochemical processes, but also through microanatomical changes that include the addition and removal of interconnections between neurons, and even the development of new nerve cellsall in order to optimize the individuals performance capacity in response to the demands of its environment. For example, a child that grows up in a hunting culture will likely develop enhanced neuroanatomical connections in the pathways that process auditory, visual, and neuromuscular function, and continue to adapt well into adulthood. Meanwhile a musical prodigy will develop the cognitive apparatus to better process musical data, and execute the coordinated hand movements required for performance. The profound clinical significance of this phenomenon is that the hardware component of our personal computers is uniquely customized, a product of our singular genetic code and the compendium of our lifes experiences. Imagine then that you are delivered a marvelously complex supercomputer that contains customized circuitry unlike any other computerutilizing not just binary bits of 0 or 1, but a variety of chemical coding systems for the storage and transmission of datawhich is contained in a protective case of multiple layers, with the understanding that if you open the case and physically intrude into the circuitry you will not merely void the warranty, but cause irreparable damage to the machine. Now tell me how it works. Quite an engineering challenge, isnt it?
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Things hardly get better on the software end of this enigma. The physiology of even the most basic cognitive function, memory, is still largely a matter of speculation. Its hypothesized that short-term memory involves the binding of a neurotransmitter to specific receptor proteins, allowing an influx of calcium into the neuronand is converted to long-term memory through a series of enzymatic reactions that leads to the synthesis of distinctive proteins within the nerve cells. Each of these neurochemical bits has to be organized in some fashion into larger cognitive structures, which function like the data and program files we have on our computers. The prevailing model for this sort of cognitive organization is synaptic plasticity, in which the strength of a synaptic connection between neurons is increased in intensity in response to repeated and persistent stimulation by the presynaptic cella process often summarized as cells that fire together, wire together. It is proposed that a number of these fortified connections assemble to form engrams, neuronal networks that each correspond to a fragment of memory. Just imagine how many such engrams are required for the construction of a single complex memory, like that of a beloved family dog! Even if we had more direct access to the brains hardware, decoding its software wonders would be a daunting taskin which we would likely be staring at trees for years before we could begin to see part of the forest. The plasticity of the brains software is self-evident, since the malleable nature of software is exactly what makes a computer the versatile tool that it is. What distinguishes its human counterpart is its remarkable capacity to innovate, reprogram, and repair itself. How else does one explain our aptitude for intellectual exploration, adaptation, invention, and creation? Or the infinite variety of cultures, personalities, interests, talents, and tastes in
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the human spectrum? These capabilities arise from our individualism, our will, and our potential for self-awarenessall of which constitute that x-factor of humanity that many have described as the divine spark. I wont go so far as thatbut I will call it that stuff that biological psychiatry cant even begin to explain. But of course, this pixie dust is just a small part of our software system. Our culture, our upbringing, our peculiar set of experiences good and bad, all contribute to the making of who we are as people, and how we are able to adapt to a myriad of situations throughout our life. Even the most individualistic among us have had to emerge from our cultures and families, and reckon with the consequent programmingsome of which is exasperatingly reflexive. How many times have we had to reconcile our admiration for some noble, historic figure of great intellect, with revelations that they were just as obnoxiously racist and/or sexist as their contemporaries were, or pathetic failures in their personal lives? Much of our software is geared toward the mundane functions of daily livingand the pursuit of exceptional goals often leads people to neglect critical upgrades for these maintenance tasks. This is the stuff of psychotherapythe programming we inherit or devise on our own that may have some adaptive purpose during a particular phase of our life, but becomes deficient as our life circumstances change. Psychotherapy is simply one of the more directive means of reprogramming our personal computer, using the communications ports associated with conversation. Other reprogramming activities may include spiritual practice, reading an enlightening book, or having a deep conversation with a spouse. However, a crucial distinction should be noted about our brains
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reprogramming process. A computer is passive, and can always be reprogrammed by its external inputeven if that input requires a password or some other security command. In contrast your brain retains the executive function, the power to either accept or reject programming input. So your brain/mind is not just a metaphorical computer, but rather computer and system administrator. (Yeah, theres that divine spark thing again.) This administrative function of the brain, the patients will, is responsible for many of the management difficulties that profoundly complicate the practice of psychiatrynot only in the matter of treatment compliance, but in the nagging questions that arise in legal, ethical, and spiritual realms about the nature of psychiatric illness and treatment. Ive spoken to some of my more biologically oriented colleagues about this computer model, and their typical response is, Well, it all ultimately comes down to biology, doesnt it?which is a definitive example of misguided psychiatric reductionism distilled to its essence. After all, a computers software all ultimately comes down to electricity, doesnt it? Well, actually, no it doesnt. When we load new software onto a personal computer, we often use a non-electronic mediuman optical discto do so. Thats because the content of software isnt electricity, but rather information, which can be encoded in electrical, magnetic, or optical mediaand could just as easily be stored in a biochemical medium as well. Certainly the individual circuits and intracellular bits of the brain are biological, just as the hardware circuitry of a computer is electronic. But a software glitch in a computer isnt fixed by replacing hardware, or the application of electricityits resolved through the reprogramming of the software, the reentry of new corrective data, which can be translated from one
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medium to another and still maintain its informational integrity. In a computer, data is stored as a bunch of electrical bits that switch between 1 and 0. If youve got a software coding error, it wouldnt suffice to apply a coarse electrical field to create, say, more 1s, because it would indiscriminately contaminate other code and disrupt any number of other software functions. Likewise, the undesirable information stored in the brain as a traumatic event or a maladaptive behavior isnt a matter of too much of this chemical or anotherits the informational content of the memory or behavioral program itself, stored across a vast multiplicity of brain cells as an array of discrete biochemical events. Without the ability to change biological code at the individual cellular level (i.e. microphysiological repair to a functionally impenetrable organ), such a treatment would have potentially disastrous cognitive effects. And if in fact biological psychiatry was poised to enter this next level of mind controlthe chemical manipulation of cognitive informational contentId be scared to death, and so should you. Fortunately, its just another grandiose fantasy that dates back to when we were slicing brainsand remember, we havent yet identified with any certainty the biochemical equivalent of a binary bit! So, lets establish once and for all that this aint the damn pancreas here, bucko! Were talking about a ridiculously complicated and convoluted organ system that has at least two planes of existenceone corporeal and one etherealwhich adds up to four dimensions, if I recall my basic math. So its unrealistic to expect too much success treating psychiatric problems if were only offering one dimension of treatment. But its said that if the only tool you have is a hammer, everything starts to look like a nail. By the same token, if the only thing you have to sell is a hammer, then you would really like all
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your potential customers to think they have a nail. The biological model offered psychiatry the opportunity to redefine itself as a legitimate medical specialty, and to secure a new post-Freudian market niche as the sole dispenser of cutting-edge treatment for mental illness. Using diabetes as a metaphor obviously promoted that role, piggy-backing on an established medical diagnosis to legitimize not only our medical treatment, but psychiatric illness as a medical diagnosis. The computer model, on the other hand, raises a whole lot of messy questions about the software (i.e. mind) as a source of psychiatric symptoms, bolstering the potential benefits of psychotherapy as a treatmentwhich could readily be provided by other disciplines. This ploy has been fabulously successful in indoctrinating the general public with the idea of mood as a chemical aberration. An amazing number of my patients seen in initial evaluation tell me that they are depressed for no reason, and have to be walked through the entirety of their psychosocial history in order to be reminded what is actually pissing them off or bringing them down. Its as if some people have utterly forgotten that they might have something to learn from their feelingswhich are instead perceived as just a bunch of nuisance symptoms that need to be blotted out. Theyre the fulfillment of every biological psychiatrists dream, a new generation of patients who think they have nothing to talk about, and just want their pill. One of the buzzwords in psychiatry today is treatment resistant depression (or TRD, naturally)which is a positive development, since it seems to indicate that psychiatrists have finally noticed that some of their patients arent getting better on antidepressants. Several times a week I receive spam emails from CME (continuing medical education) websites
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touting articles like Intervention Strategies for Unresponsive Depression, or Addressing the Needs of the Treatment Resistant Patient. Childlike, I open them with the foolish hope that someone will be recommending deeper exploration of marital issues, or instructing psychiatrists how to screen patients for referral to cognitive behavioral therapybut sure enough, theyre inevitably recommending augmentation of the antidepressant regimen with a mood stabilizer, or some diabetogenic antipsychotic medication associated with godawful weight gain. But of course its exactly what I should expect: Your current selection of hammers isnt working? Then try another hammer! Given this bad attitude, you might wonder how I account for the success that psychiatrists have in fact had with medication therapy. As Ive said before, contemporary psychiatric treatment is more effective than its ever beenmostly because todays medications are genuinely better than ever, even if our clinical practice isnt up to snuff. But how can a hardware solution like medication effect improvement in as many patients as it does? Reexamination of the computer model provides some limited support for this possibility. If a computer was performing sluggishly due to corrupted software code, one could conceivably speed it up by cooling it down to below 30 degrees Kelvin (-406 degrees Fahrenheit), at which point metals begin to exhibit superconductivityassuming that the hardware was physically fit to survive this extreme temperature. This would speed up computer processing, without correcting the deficient code. It should be acknowledged, though, that the computer model becomes quite strained here, since the computers hardware function is restricted to simply crunching a vast array of redundant binary bits. The brain, on the
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other hand, comes out of the box with a lot of hardwired firmware installed ready at birth to take on regulation of the bodys autonomic functions, to interact sufficiently within a nurturing environment to see that its needs are met, and with a basic operating system in place to provide a template for intellectual and physical growth. But as imperfect as it is, the computer is nonetheless the best mechanical model we have, if for no other reason than that it clarifies the relationship of the mind to the brain. In doing so it calls attention to the egregious deficiencies of the biological approach in its gross neglect of software issues, and raises questions as to the potential limits of medication-based therapy. Not so long ago the computer industry was dominated by IBM, widely known then as Big Blue. When Apple started the personal computer revolution, IBM responded by creating a standardized PC hardware platform, and outsourcing the development of an operating system and its software applications to a small company called Microsoft, led by a geek named Bill Gates. The rest is history, and IBM is now a bit player. There is a distinct possibility that the potential for medication intervention in psychiatric disorders will prove over time to be limited in its scopeand that in our headlong rush toward hardware solutions, psychiatry may be replicating IBMs disastrous error. Sounds crazy? Maybe so. But like I said beforein this business, one never knows what they dont know.

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