Origins And Mechanisms in the Development of Major Mental Disorders (A Novel Approach)

Empirical evidence and previous research demonstrate shared characteristics which together play a crucial role in the development of the MMDs.  These characteristics readily apparent clinically, are overlooked in their collective significance for the development of the MMDs.

The characteristics and their significance are:

1. The significance of inborn propensities. (Temperament)

The underlying temperamental variances in all MMDs should be viewed as extreme degrees of the normal occurring types (Normal temperamental components do not impair relationships and actions, nor create discomfort or anguish under normal circumstances as they represent inborn behavioral tendencies expressing variable styles for coping and survival as well as contributing to the survival of an individual’s tribe). They represent underlying, structural, variances in the very architecture of the brain (Steinmetz, 1986).

Temperament, a very important but grossly understudied phenomenon can be defined as the inborn “How” of behavior and is made up partially and somewhat controversially of the following elements: emotionality/affectivity (feeling the world), intensity/reactivity, “cerebricity”(e.g., thinking the world), sociability, aloofness/social shyness, compulsivity, inner-directedness, other-directedness and possibly others ((Chess, 1996; Pediaditakis, 2002; Eysenck, 1992).  These elements tend to occur in clusters of various, often distinct, combinations, constituting the temperamental types (Jung, 1971; Cloninger, 1993; David, 1998).

Temperament can be seen also as a scaffold on which a person’s personality is built by the impact of myriad environmental influences. Selective significance of these environmental influences is affected by the very temperament on which they act, adding lifelong attitudes and habits as well as early imprints (faulty or not.). Together, these eventually comprise the totality of the coping ways and style of the individual’s established personality.

Temperament, in addition to its role in MMDs also appears to play significant roles in the individual’s life; it is partially involved in mate selection for the formation of procreational dyads (insures longevity necessary for the premature human baby)as well as for lasting partnerships (Pediaditakis, 1998). It contributes to one’s lifestyle and vocational choice within the framework of contingency and circumstance. It also acts as a possible facilitator (when an extremely variant) in gifted and talented individuals to connect their talents into creative channels by mechanisms not yet clear (Andreasen, 1987; Jamison, 1989; Jamison, 1989).  By evolution, temperament may contribute specific benefits to the group as a whole not only to the individual bearer.

In the case of schizophrenia, the preexisting extreme temperamental variances before the onset of the disorder make up the pre-morbid personality (Arieti, 1959). At the onset and relapse, they are now considered part of the disorder and named the negative symptoms even though having been part of a patient’s temperament all along as the patient himself and relatives ascertain if asked (Young, 1996). In contrast, the appearance of the periodic psychosis heralding the onset and naming of the disorder are called the positive symptoms. The different terms for the same clinical phenomena used during different times of their course act as a semantic trap.  Actually, the positive symptoms should be viewed as periodic epiphenomena on these preexisting, extreme temperamental variances (Kaplan, 1994). The preexisting specific variances in other MMDs, on the other hand, are not usually considered causative factors in a disorder and usually with rare exceptions, they are ignored as to their causative role or merely labeled as traits (Hirshfeld-Becker, 2003; Benis, 1986). Those extreme temperamental variances for each disorder remain unaffected in remissions and specifically for schizophrenia are now called “residual symptoms” now often mixed with some lingering positive ones (Szöke, 2002; APA Diagnostic and Statistical Manual of Mental Disorders, 1994; Arolt, 1994).

It appears that individuals with extreme temperamental variances constitute a pool of vulnerable candidates Some of these candidates will subsequently and probabilistically develop a MMD usually in late adolescence, presumably under social and hormonal pressures as well as other possible elements (e.g., pruning) acting as precipitating factors.

In schizophrenia, the preexisting, extreme temperamental variances that occur in various combinations include; aloofness, apathy punctuated by occasional explosivity, excessive social uneasiness, self-absorption, absence of empathy, excessive “cerebricity” (thinking the world) and an inability to accommodate ambiguity.

In obsessive-compulsive disorder (OCD), there preexist specific extreme temperamental variances such as in accommodating ambiguity and displaying flexibility of response to a given situation. The affected individuals tend to be captive to algorithms. They express a mirthless attachment to exactitudes as they perform their tasks (APA Diagnostic and Statistical Manual of Mental Disorders, 1994).

It is important to note that in the case of OCD, the emergence of disorder may take place, irrespective of preexisting temperamental extreme variants.  It appears that it occurs in situations where the brain functions are threatened by perceived dangers from within or without. It can be considered an emergency response for a sense of order.  Examples include post brain trauma sequelae, or prodromal symptoms of impending psychosis or the individual’s response to severe external pressures (Iida, 1995).  This is similar to the hero in the film “The Bridge Over River Kwai,” or the abused wife in the movie “The Tin Drum,” who compulsively ended up eating raw sardines.

In bipolar mood disorders the preexisting extreme variances may include the following; an undue emotionality, acute sensitivity to even mild social stimuli, obsessive behavior, and an emotional entrainment perceived by the patient variously as an “inner, frozen, landscape,” “emotional shackles” or a sense of “woodenness,” as the sufferers will explain in response to inquiry (Akiskal, 2003).

In borderline disorder (a misnomer, i.e., borderline to what?), the prime temperamental extreme variant, which primes the triggering of the frequent, spectacular but brief, oscillatory symptoms across ALL the higher mental faculties includes mainly hyperintensity/reactivity (hence, in passing, a better term for the disorder could be “disorganizing hyperintensity disorder.”) Additional temperamental variances for this disorder are lack of empathy and undue self-absorption (Neal, 2003).

In phobias, anxieties, and panic attacks, the extreme temperamental variances for all MMDs may include the presence of excessive sociability and obedience to social gestalt, excessive empathy and sensitivity to social expectations and stimuli (Neal, 2003).

The preexistence of temperamental extreme variances for all MMDs with the implied underlying structural variance, antedating the psychotic phase of the disorders suggests a common underlying vulnerability which may be “a sensitivity to the initial condition” for the eventual possible compromise of the overall operating mode of brain function from a normal into a periodic appearance of a pathological phase in the development of MMDs (Pediaditakis, 1992).

2. The significance of comorbidity and overlaps during the expression of the MMDs

In all MMDs, comorbidity is ubiquitous (Maru, 2003; Moeller, 2001; Mitropoulou, 2002; Klein, 2002). The syndromes named, rarely if ever, conform to the procrustean categorical guidelines of the current nosological schema of the Diagnostic and Statistical Manual IV and its international nosological version ICD10. MMDs often coexist or partially overlap. As G.Claridge aptly states: “Practical manuals” are based on categorical divisions of MDs that may or may not be valid and merely reflect the latest zeitgeist. The psychoses are especially problematic in this respect, because of difficulties in defining their exact boundaries. This leaves considerable room for disagreement and debate which the ICD and DSM do not address (Claridge, 1980). DSM-IV, practical as it is for billing purposes, resembles the old Ptolemaic schema for planetary motions in that it confounds the Ocam’s razor for simplicity. In addition, DSM-IV’s procrustean guidelines may be the source of serious flaws in research designs and outcomes. It was developed to be descriptive and neutral as to the causes of MMDs. Treating MMDs as if they are distinct, separate entities prevents us from discerning the significance of these phenomena (Dilling, 1994; Taylor, 1993; Fergusson, 1993; Doyle, 2002).  Actually, the idea of the existence of a unitary psychosis (Einheitpsychose) antedates Bleuers and Krepelin’s construct from which the current DSM-IV originates. In practice, we accommodate this “messiness” by using terms like “schizoaffective disorder,” “mixed,” “atypical psychosis” “schizotypical,” or “non-elsewhere-classified”!

The existence of these overlaps and comorbidities add to the evidence suggesting a common initial developmental origin.

3.  The significance of sharing a family genetic pool.

Among family members of patients with MMDs, there exists at a higher rate (16%) than among the general population roughly (3%) of similar or different MMDs as well as extreme temperamental variances (Grant, 2004).  In identical schizophrenic twins, the rate is approximately 50% for their co-twins (Pediaditakis, 1996; Baare, 2001; Freeman, 2002; McIntyre, 2003).  This suggests a common initial developmental origin.

4.  The significance of periodic relapses, remissions and clinical shifts

All MMDs, given time, regardless of treatment at least in the initial period, will remit and relapse while the underlying extreme temperamental traits remain the same. During relapses, the clinical symptoms often shift from one “typical” syndrome to another, requiring a new diagnosis (Freeman, 2002).Ironically; Mental health professionals often assume error by the previous diagnostician in an effort to conform to the categorical guidelines.

These phenomena suggest a potential bimodality of the operating mode (i.e., oscillating from the normal phase with the qualities of synchrony and amalgamated subtlety to a pathological one expressed with either-or, crude, antithetical substitutes characteristic of the symptoms of all MMDs). They also suggest a causative role of the underlying temperamental variance as well as a common initial developmental origin.

5. The role of sharing responses in the administration of psychopharmacological agents and ECT

Currently available psychotherapeutic agents are moderately effective albeit, across the spectrum of all MMDs. They, in fact, target a single symptom or even symptoms across syndromes, irrespective of the named syndrome as they usually target particular neurotransmitters McIntyre, 2003; Yatham, 2003)

The current, widely used poly-pharmacy (i.e., the concomitant use of multiple agents each targeting different neurotransmitters although the same symptoms) has better results (Leslie, 2001).

These phenomena suggest that the overall operating mode of brain function is sustained by a complex and subtle interplay of many neurotransmitters as well as the multifunctional role of a single neurotransmitter. They also suggest that the mode is an emergent phenomenon of complexity. This is additionally suggested by the delay in the appearance of therapeutic results (Akiskal, 2003; Pezard, 2001).

Clozapine, a dramatically effective drug (but unfortunately, dangerous agent to its side effects) affects several different neurotransmitters (Breier, 1994). This too suggests a common developmental origin as well as a common operating mode of brain function.

Again, ECT as well as Metrazol and Insulin convulsive therapy of old, affects temporal remissions across the entire spectrum of MMDs by the off and on disruptions of brain functions restoring for a time the normal mode. (Wijeratne, 1999). (It is a kind rebooting the operating mode of brain function.)

6.   The significance of the overall operating mode of brain function in MMDs.

Most significantly, during the onset and relapse of MMDs, the fundamental and overall property of the brain, which normally ensures a synchrony and smoothness and determines elegance and grace in the expression of all higher mental faculties, is now replaced by ( pathological ordered system) an either-or crudeness in the expressions as well as misalignments, as the symptoms become antithetical substitutes. These pervasive, either-or substitutes can be considered as a sort of “Psychic-Parkinsonism.” Detailed examples of such substitutes have been enumerated elsewhere (Pediaditakis, 1992; Pediaditakis, 2002).

Additional examples involving individual faculties are presented here: In the faculty of mood modulation, the occurrences of mania, (i.e., the presence of unwarranted, emotional effervescence and exuberance), followed by depression, (i.e., the equally excessive, unwarranted sadness and pessimism) both emotional states influence thought and behavior.  They also oscillate from one extreme to the other, replacing the previous, amalgamated state of normally-felt, zest mixed with a certain sobriety, constraint, delicacy and subtly. In mixed bipolar disorder, severe anguish and sadness coexist (actually as a rapid oscillation) with incongruous joviality and mirth. In the faculty of orderly thinking and the alignment of thinking with sentiments and actions there lies schizophrenia. In schizophrenia, the expression of this faculty breaks down into separate, unamalgamated components, seemingly expressed concomitantly as schizophrenic ambivalence (i.e., the appearance of rapid oscillating sentiments toward the same person.) In addition, the functions of orderly thinking and alignment of thinking, sentiments, and appropriate actions are now uncoordinated with the emergence of the positive symptoms consisting of thought disorder (i.e., decoupling in thinking from the Aristotelian rules) with the appearance of odd, unpredictable, non-sequitor association as well as misalignments among thinking and actions as the word schizophrenia (Gr., torn-brain functions) graphically implies.

In hallucinations and delusions, the mechanism is not clear. It may plausibly result from the decoupling of one’s internal, normal dialogues with oneself (reflective thinking and contemplation). The internal dialogues are now perceived as “coming from external sources” not the patient himself and are identified as “voices.” Similarly, in delusions, usually persecutory, it may be that the brain attempts at a coherent, concrete explanation of the perceived, self-monitored danger of itself during the pathological phase of its overall operating mode. While delusions of grandeur may be an attempt to coherently explain the felt, unwarranted emotional exuberance. The antithetical substitutes phenomena can be best witnessed in their startling form when borderline disorder flares up. The patient oscillates in behavior, expressed feelings, and attitudes within minutes, often in the presence of the examining clinician (Pediaditakis, 2002).  For example, a young, female, sufferer may seem to be a ferocious vixen and then quickly “morphs” into a helpless waif.

In OCD, the normal algorithmic faculty of the brain that imparts a smooth orderliness in fore planning, scheduling, and sequencing of one’s actions switches to a pathological phase. The normal algorithmic faculty is replaced by either-or, ritualistic, repetitive acts- a caricature of order- and entrainments of ideas (e.g., obsessions). There is also a notable difficulty to bring closure to a thought or action and in addition, the frequent appearance of intrusive, rebellious, “nasty” thoughts which alternate with excessive piety and periods of slovenliness as well as neglect of one’s affairs (APA, 1994)

If taken into account collectively, then each cluster of symptoms which are often variable and overlapping in their periodic appearance as they make up the familiar syndromes of each of the MMDs, can be considered a clinical expression of a “local” (i.e., functionally circumscribed for a particular faculty) perturbation/oscillations of a common, overall operating mode of brain function. Such perturbation can involve more faculties in the presence of comorbidity. The existence of an overall operating mode of the brain’s neural network is mentioned explicitly in the literature (Pediaditakis, 1992; Skarda, 1987; King, 1991). This mode normally imparts and then oversees the synchrony, coordinated smoothness, and amalgamated subtlety, exhibited during the expression of all higher individual faculties. It represents the very essence of being normal and is similar to the one mediated by the basal ganglia which insures the coordinated smoothness and elegance exhibited during our body movements providing the typical non-robotic appearance of humans in motion.

7. Proposed a natural history and sequences in the development of MMDs

When all of these phenomena are considered together, we can discern the sequence of events leading to the occurrence of a MMD: Individuals with inborn, extreme temperamental variances (with the implied, underlying, extreme structural variances) make up a group of vulnerable candidates. A certain percentage of these will probabilistically develop into a MMD. We can also consider that these disorders share a common, initial, structural vulnerability several steps removed from the final structural outlay (i.e., the fractal, dendritic development) of the brain and therefore its final functional reality). Whether a disorder will actually develop in a particular area of higher brain function depends on two of the following factors; one is the degree of the structural variance expressed as a temperamental extreme which confers vulnerability in a particular faculty in the brain or faculties in the presence of comorbidity. The other factor is the entire range of environmental influences as they act upon the brain.

A mental disorder will occur in some of these vulnerable individuals (usually in adolescence presumably triggered by hormonal and social pressures as well as by other possible factors) as a probabilistic phenomenon, amenable to prediction only with statistical methods (with around 3% for each of the disorders prevalence for the general population worldwide). If the extreme temperamental variance is located mainly in a functional part of the brain controlling mood modulation, it makes the victim vulnerable to possible periodic occurrence of oscillations resulting in bipolar disorder. If it is in the area controlling social connectedness, thinking processes and coordination of feelings and ideas, it will express itself as schizophrenia. If it is in the algorithmic area of the brain that controls orderliness, sequencing, scheduling, and advance planning, it will express itself mainly in the various phenomena of compulsions or obsessions. If it is in the area of the brain that controls perception of danger from within (anxiety) or without (fear), it will then show up mainly in panic attacks, phobias and anxiety disorders as well as OCDs. If it involves temperamental hyper intensity, it may express itself briefly and periodically involving some or even all faculties-as in the flaring up of borderline phenomena.  After the first occurrence (onset), usually but not always, the operating mode becomes unstable and bimodal (i.e., switching phases periodically from normal to the pathological and back again) in relapses and remissions. During the periodic appearance of the pathological phase, the particular faculty/function affected expresses itself in an either-or fashion with the appearance of symptoms as clusters of oscillating, antithetical substitutes characteristic for each disorder. It is as if the conductor of an orchestra during a musical performance suddenly abandons the orchestra. The phenomena are akin to Parkinson’s disease where awkward, spastic, either-or, and zombie-like, painful-to-observe body movements have replaced normal elegance and grace of motion. The latter mediated by the basal ganglia.

Stemming from these considerations, the statistical prevalence for each MMD can be considered as a downside tradeoff of the brain’s evolutionary deployed advantages.

The preexistence of temperamental extreme variances for all MMDs with the implied underlying structural variance, antedating the psychotic phase of the disorders suggests a common underlying vulnerability which may be “a sensitivity to the initial condition” for the eventual possible compromise of the overall operating mode of brain function from a normal into a periodic appearance of a pathological phase in the development of MMDs (Pediaditakis, 1992).

8.  Conclusion

Consideration of the above, shared phenomena in their collective significance suggests novel ways of answering the baffling questions of “how-the-brain-does-it,” with respect to the higher mental functions in health and disease alike. In this paper, some propositions have been made as to their significance, based on the persuasiveness of the readily observable phenomena. Becoming alert to these will protect us, as well, from reaching erroneous conclusions in clinical studies because of rigid Procrustean guidelines for selecting our subjects. These proposed concepts can also allow us to consider new ways of viewing the mechanism of the development of mental disorders and develop new, more effective and safer therapies (i.e., modulated chaotic signals applied in lieu of ECT in an effort to restore the operating mode as the ECT does, after being tested for safety in animals, volunteers in research and then patients). In closing, to use a metaphor: busy as we are in studying the individual trees, there is merit in pausing and considering the forest as a whole, with its own telling, emergent qualities.

Acknowledgements

My gratitude and appreciation to Dr. Nicholas Stratas, MD, DLFAPA, Dr. David Servan-Schreiber, MD, PRD, Dr. Robert Webbie, MD, PhD, Dr. Peter Pediaditakis, PhD, and Dr. John Rather, PhD for helping and advising me as to how to best express my concepts in the paper and also, my daughter, Nicole for the endless editing.

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Nicholas Pediaditakis, MD, DLFAPA
5100 Lead Mine
Raleigh, NC 27612

niko15@bellsouth.net

http://www.npediaditakis.com

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