CHAPTER 11. THE ROLE OF NEUROTRANSMITTERS IN MENTAL ILLNESS
Perhaps nothing shows the shortsightedness of the sociology than its treatment of mental illness as an aspect of deviancy. The argument that mental illness should be included as a part of deviancy because it deals with people who are different in the norm, is as ridiculous as including neurological disorders as deviancy because its sufferers act differently from others. Illnesses definitely connected to physical disease are not to be included in deviancy. Therefore, mental illness should not be included in deviancy because it has definitely been shown that all categories of mental illness are connected to physical disturbances in the brain, namely, chemical imbalances. Of course, mental illness varies by categories of social class, race, and many other sociological variables, but so too does head injury. But we do not include head injury in discussions of deviancy. This type of reasoning also helps feed moralistic understandings of mental illness as the result of "perversion," "sinfulness," or "lack of willpower."
There are, of course, sociological contributions to the etiology of mental illness. The argument in this chapter is not to show that these associations do not exist, but that a simple social causal model of mental illness is downright misleading. Mental illness has been shown to have a very strong genetic base. Oftentimes this mental illness does not manifest itself until some social or other stress is placed on the individual.
Even if we admit that social forces affect mental illness, there is still the situation where these social forces have to act through changes in body chemistry. The social variables, therefore, are influenced by the biological ones. And, the fact is, that not everyone subject to the same social forces actually develops mental illness. Rather there is a continuum of biological susceptibility to mental illness as the result of stressful and traumatic factors. In short, there is no way in which sociologists can avoid biological factors (but why should they even want to, except for political reasons?)
Thanks to the great advances in psychopharmacology we not only understand more about the nature of mental illness, but can also effective treat it without decades of mental therapy. The role of neurotransmitters is slowly producing a revolution in the way we think about not only mental disorders, but also deviant acts. Despite the resistance to the new science of neurotransmitters in the social sciences, this view is now quickly becoming the dominant one in the fields of psychiatry. The next inroads will be in the area of psychology.
Research in Psychopharmacology
Chemical research into the physiology of the brain continued despite the fact that in America it was not regarded as very relevant to psychology and sociology. Much of this research, however, went on in the more hospitable, less puritanical-moralist Europe. Research in American concentrated on the medical field of neurology separated off from the broader field of psychiatry and psychology. While America fell in love with Freudian psychology, Europeans continued a medical, psychopharmaceutical approach.
Outside America, psychiatry had made considerable advances in England and France in the early nineteenth century (Spiegel, 1989:31-33). A classification of mental illnesses based on observation and statistical comparison was developed by Philippe Pinel (1745-1826) and J. E. Esquirol (1772-1840). In his textbook of 1838, Esquirol spoke of "mental illness" instead of the previously used term "alienation," thereby, insuring the victory of the medical model over spiritualistic concepts. With Wilhelm Griesinger (1817-1868), the German school of psychiatry underwent a similar transformation. Griesinger, however, devoted very little space to the use of medicaments in the treatment of mental illness. The German Emil Kraepelin (1856-1926) developed a psychiatric classification, the essential features of which still remain valid today. His textbook on psychiatry (1899) makes various references to the use of pharmaceuticals in the treatment of the mentally ill. Psychiatrists used several preparations to sedate raging, anxious, restless, or sleep-disturbed patients. Kraepelin was also the first to formulate a scientific description of manic depression.
The years following Kraepelin's pioneering efforts met with very little progress (Spiegel, 1989:32). The textbooks of Eugen Bleuler (1857-1939), appearing between 1916 and 1949, show little improvement in the list of drugs used to treat mental illness.
The first demonstration of a chemical neurotransmitter was that of acetylcholine. The year was 1921 and the scientist Otto Loewi. The big breakthrough, however, came with the discovery of modern psychopharmaceuticals. In 1948/49 came lithium followed in 1952 by chlorpromazine. Following the discovery of chlorpromazine the field really skyrocketed, and there occurred a flood of new drug discoveries: meprobamate in 1955, imipramine in 1957, and chlordiazepoxide in 1958. Published in 1975 was the news that pharmacologist Dr. Hans Kosterlitz had identified the brain's own opiates, enkephalins.
One knows that a new school of thought is making progress when the proponents of the old school directly attack it. Such is the case for the psychopharmaceutical approach in psychiatry, attacked by Dr. Breggin in his Toxic Psychiatry (1991). Breggin complains that the new/old biopsychiatry has so taken over the profession that in some psychiatric training programs, such as John Hopkins University School of Medicine, psychotherapy is no longer a required course, and in most others it gets short shrift. Breggin claims that the new school is without moral compassion, and has turned psychiatry into mere chemistry. He claims that compassionate psychologically oriented psychiatrists have been replaced by biochemists and lab researchers, who, along with the major journals, devote nearly all their energy to studies on the brains, blood, and urine of psychiatric patients.
Breggin (1991:12) complains that some leading psychiatrists now propose to eliminate psychotherapy entirely from the basic training of psychiatrists, something that already has occurred in individual programs. British psychiatry has outpaced America in adopting biopsychiatry as all of psychiatry. In the July 1983 British Journal of Psychiatry, B. A. Farrell surveyed "The Place of Psychodynamics in Psychiatry" and found that "mainstream" psychiatrists now believe that psychological approaches are of "no use" in their thinking or their actual work. The same is true in most European countries. Unfortunately, Dr. Breggin is part of the old guard trying to stem the flow of progress of the new scientific paradigm. Even in the face of virtual "miracle" cures in psychiatry, the old guard staunchly defends the outdated conceptions of psychiatry.
Four Major Syndromes of Mental Illness
A very popular book, and one that is easy to read, is Nancy Andreasen's The Broken Brain (1984). The break in the brain leading to mental illness is a breakdown in neurotransmitter systems. Mental illness is due, among other things, to chemical imbalances in the brain and treatment involves correcting these chemical imbalances. The new psychopharmaceutical drugs work precisely because they help restore this break in the brain, reestablishing the proper balance of the brain's internal chemicals.
There are four major syndromes of mental illness, and all four have been found to be related to disturbances in neurotransmitter levels. The first group of syndromes contains the affective disorders. The word affect refers to the emotional side of humans. There are two main categories of affective disorders: unipolar or depressive disorders, such as regular depression, and bipolar or manic disorders, such as manic- depressive disorder in which the patient swings between moods of extreme depression and high mania.
Scientific studies (Cooper, et al., 1991:278) have shown that depression can be caused by a functional deficiency of serotonin or norepinephrine, or both. Depression has been found to be associated with a deficiency of catecholamine (usually norepinephrine). Mania results from excess catecholamine. Drugs that tend to depress behavior in animals and humans often reduces synaptic activity at catecholaminergic synapses in the brain and elsewhere.
The schizophrenic disorders constitute the second area of mental illness. Schizophrenia is actually a large group of disorders. A common characteristic, however, is disordered thinking (often involving delusions or hallucinations). A number of neurotransmitters and neurotransmitter related chemicals have been found to be associated with schizophrenia, including: altered functions of serotonergic systems (Cooper et al., 1991:357); low MAO levels, particularly in those of the paranoid type (cited in Zuckerman, 1979:342); and an excess of dopamine. (A deficiency of dopamine is correlated with Parkinson's disease.)
Three areas constitute the third category of mental illness. The anxiety disorders contain phobic, anxiety, and traumatic stress disorders. Phobic disorders include agoraphobia, social phobia, and simple phobia. The anxiety states are examples of irrational anxiety of a general nature. Unlike the phobias, they are not tied to a specific stimulus. Rather they are characterized by pervasive and persistent anxiety. Anxiety states include panic disorders, generalized anxiety disorder, and obsessive-compulsive disorder. And, finally, post-traumatic stress disorder includes acute post-traumatic stress disorder and chronic post-traumatic stress disorder.
Anxiety may stem from the pons portion of the brain stem, especially the locus ceruleus. Norepinephrine mostly originates from cells in this tiny blue nucleus. Patients who have panic attacks tend to have higher levels of epinephrine, suggesting some abnormality in the catecholamine system. Some antianxiety drugs work to enhance the effect of the neurotransmitter GABA. This in turn slows down those brain systems, such as the norepinephrine system, that stimulate arousal or anxiety.
Dementias constitute the fourth area of mental illness. These are serious brain disorders, including the devastating Alzheimer's disease. Acetylcholine is the neurotransmitter implicated in Alzheimer's disease. Patients with Alzheimer's also have decreased levels of somatostatin, neuropeptide Y, and NMDA receptors. In addition, they have reduced numbers of locus ceruleus neurons (Cooper et al., 1991:214). GABA has also been implicated in the pathogenesis of senile dementia.
Mental Illness as a Response to Trauma
Heredity plays a very important role in mental illness. But, even very healthy persons can develop conditions of mental illness if subject to traumatizing events. This can be seen in soldiers subject to combat conditions. These condition can produce post traumatic stress disorder (PTSD). (See the chapter on rape for an illustration of the response to this traumatic event.) This is an important area of study because many problems of mental illness may be a physiological responses to stress. Many depressive episodes have external stimuli, such as the death of a loved one or the loss of employment. These traumata might excite the serotonergic system causing excessive or abnormal depletion of the supply of serotonin. This is a possible synergistic relationship between biochemical and psychocultural explanations. Kushner, 1988:174
The primary feature of PTSD is that the stressor be of significant magnitude to evoke distinguishable symptoms in almost everyone (Burgess and Holmstrom, 1985:49-53). The second major diagnostic criterion of PTSD is re-experiencing of the trauma, most frequently evidenced by recurrent and intrusive recollection of the event. Day images are common with some event or happening triggering the memory. The victim may feel as though the traumatic event were recurring. Sometimes they may see danger signs or the perpetrator everywhere they go. They may even search him out. Nightmares are also common, often repeating the traumatic situation. The third major diagnostic criterion is a numbing of responsiveness to or reduced involvement with the environment. Sufferers talk of being in a state of shock or a feeling of unreality as if it had not really happened. The sufferer may not be interested in former activities, feeling isolated and estranged from others. They may withdraw from life. The fourth criterion states there should be two of the following lists of symptoms that were not present prior to the trauma: exaggerated startle response of hyper-alertness; disturbances in sleep pattern; guilt about surviving or behavior employed during the trauma; impairment of memory and/or power of concentration; avoidance of activities that arouse recollection; and increased symptoms to events or incidents that symbolize or resemble the traumatizing event.
The body responds to these traumatic events in terms of anxiety and depression. Studies should be done detailing the physiological changes involved in the trauma reactive phases. Some people are probably more prone to mental illness and a trauma may induce terrible problems of mental illness including fearsome phobias, such as social phobia or agoraphobia. Therefore, it is mean-spirited and moralistic to point out to some sufferers that they should bounce back just like such-and-such a person did. The real probability of healing can be held out, but not in a moralist and recriminating spirit.
Fortunately, since the body responds physiologically in ways that resemble inherited mental illness, many of the stress responses to traumatic events may be handled with drugs currently being used to treat mental illnesses. Another example of an intimate relationship between chemistry and social behavior can be found in the relationship between dietary habits, which are gender-, ethnic-, and class-specific, and serotonin (Kushner, 1988:171-172). Brain levels of serotonin are associated with successful suicide attempts. Serotonin's chemical precursor, the amino acid tryptophan, is one of the essential amino acid. Lean meats, poultry, fish, and peanuts are rich in tryptophan. Evidence suggest that suicide completion has been historically lowest among specific populations such as women, the Irish, and the Italians, whereas it has been highest among white males, Danes, Austrians, and Germans. Since these groups obviously differ in diet, this could affect the level of serotonin. Further research, however, is needed.
Neurotransmitters are not just involved in mental illness. Rather they are involved in all brain processes, including the development of personality. One example is the personality characteristic of risk-taking. Astronauts were said to have the right stuff. Some of this right-stuff is the correct brain chemistry. And one of the most crucial chemicals in risk-taking is MAO. Zuckerman (1979) has summarized much of the research on MAO and risk-taking, which found that high-MAO monkeys were solitary, inactive, and passive, whereas low-MAO types were active, making many social contacts and engaging in vigorous play. Other research has noted that MAO-inhibitory drugs tend to produce hyperactivity and increased open-field activity in rodents. Research in humans has also shown that high-sensation-seeking humans have low MAO levels and conversely, that low-sensation seekers have high MAO levels.
Stage Fright is another area in which neurotransmitters play an important role (Restak, 1984:171). Messages from the brain pass down through the nervous system. The noradrenaline produced by this passage of nerve currents makes the heart beat faster; it also stimulates the adrenal glands to give off adrenaline, which pours into the bloodstream. It is the adrenaline, coursing through the bloodstream, that maintains the rapid heart rate and induces the trembling and sweating of stage fright.
Beta-blockers (or propranolol, marketed under the trade name Inderal), used primarily for the treatment of high blood pressure and irregular heartbeat, act by blocking some of the effects of norepinephrine, a hormone released in large amounts by the body during periods of stress. Norepinephrine is in part responsible for the increased heart rate, shakiness, and stomach upset common in a stressful situation (Winger 1986:28; Restak, 1984:171). The beta-blockers fit into the adrenaline "keyholes" on the heart. Since the keyholes are already filled, circulating adrenaline can't lock onto the receptor and speed up the heart. Therefore, the sufferer from stage fright can still become "psyched up" for a performance but no longer have to contend with the disturbing manifestations of stage fright.
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