Genetic fatalism in mental disorders

In the spirit of keeping the conversation on mental health going, I would like to draw your attention to the way we think about genetic-based serious mental illnesses. These illnesses, as a class, involve the most psychologically intrusive disorders, including schizophrenia, bipolar disorder and post-traumatic stress disorder.

In the treatment of SMIs, it is at times appropriate to prescribe medications and institutionalize patients without their consent. The resistance to being treated, the argument goes, is a symptom of the disorder — a patient would want treatment if that mental disorder weren’t clouding his or her judgment.

There’s even a name for it: anosognosia, not understanding that one has a mental disorder. Indeed this lack of awareness is the major dividing line between credible refusal and symptomatic delusion.

Someone in possession of self-awareness, however, is considered by practitioners to have “insight.” While a prerequisite to writing advance directives, insight is also critical to active management of disorders, which can affect patient outcomes to a greater extent than the insight/anosognosia divide might suggest.

Elyn Saks, a professor at the USC Gould School of Law, who has schizophrenia, collected management strategies from several dozen schizophrenia patients. The strategies, mostly thematic, vary with the individual person and the individual case of schizophrenia.

One common strategy is to restrict the amount of sensory input that flows into the schizophrenic brain. One patient had no decorated walls, loud music or television in his home. Another deliberately listened to loud music to drown out his hallucinations. Would both of these strategies work in either patient?

While genetics are the first mover, SMIs in particular interact with an individual psyche, and how that psyche respond — either tempering, shouting down, or tiptoeing around — will vary by person and, in principle, by disease case, as there is no one genetic cause of schizophrenia. The study of these disorders often stops at the psychology 200-level, and some freshmen seminars offer mental health-related topics.

Seeing themselves in a broader social context is helpful, whether through work or faith. Perceiving value of oneself and depersonalization can oppose symptoms or subsume the patient to a larger, less personal structure and self-image. One can easily imagine the role stigma, including on this campus, would play in alienation (and the subsequent worsening of symptoms) of patients with SMIs.

Steps can be taken at the societal level, too. The justice system in particular may be doing both harm and good when evaluating mental competency. Stressful situations and isolation are both major risk factors for bipolar disorder, and can cause or worsen intense episodes. For a school with a major policy focus, we ought to have a few campus organizations tailored to mental health and public policy.

Just as SMIs interact with patients, the broader world interacts with the disorders. In one salient example, a patient with bipolar disorder, Linda Bishop, was arrested for drunk driving and imprisoned for eighteen months for refusing to pay a $500 bail. The stress and social isolation undoubtedly worsened her symptoms, and these triggers might have caused the judgment that she was mentally unfit for trial, since she was a border case before the driving incident.

If mental disorders are thought of negatively, especially as signs of personal weakness, those with bipolar disorder might discredit diagnoses entirely or blame themselves, owing in part to the symptoms of mania and depression, respectively. For students grappling with these disorders, seeing SMIs as interacting with psychological persons can inform their own sense of place and responsibility.

Indeed, stigma might be the toughest obstacle, paradoxically attributed both to the “sick person” with no control and the “weak-willed person” with total control. Ousting these images can only improve the lot of those suffering from SMIs.

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Inter-disciplinarily inclined students should be interested in a holistic survey course on the public perceptions of mental health — something which might serve as a bridge to the wider world of practical, nation-level studies for students accustomed to studying individual minds.

Understanding SMIs as part of a larger personality, and personalities as part of a larger social context, is essential both for active management on the part of the patient and in forming a body politic versed enough in these public health problems to actively manage them.

We have the good fortune to have a fully funded psychological counseling service for students, but other universities — simply google “In Sight, Out of Mind” for a particularly salient example — do not extend the same generosity. Nor do we go far enough in understanding these disorders for what they are — a missing piece in an otherwise equally complex and dynamic puzzle.

James Di Palma-Grisi is a psychology major from Glen Rock, N.J. He can be reached at jdi@princeton.edu.