Kandel, The disordered mind. Or was Descartes wrong?
It’s become almost commonplace today, at least among those impressed by the latest results of neuroscience, to say that Descartes got it backward. Not “I think therefore I am,” but “I am therefore I think.” The mind is composed of body. The brain makes mind possible.
This is the argument of Eric R. Kandel, author of The Disordered Mind and Nobel Prize winner for his research on memory storage in neurons. The reader need not be intimidated. Kandel clearly explains recent developments in neuroscience for the non-specialist. He tries, but fails, to put together the neuroscience of the injured brain with the experience of emotional distress. He knows one is incomplete without the other, he calls for a “new scientific humanism,” but all he ever says is that both brain and experience need to be taken into account. Sometimes that’s enough, but about some experiences, such as PTSD, he cannot get out of the brain.
I feel therefore I am
It’s absolutely true that brain makes mind, and yet this is not how we experience ourselves. “I feel therefore I am” is probably the first and fundamental experience of self, and it would not be wrong to say that feeling is at least as body-based as it is mind-based. The fundamental experience, or at least the experience that makes life worth living, is the feeling of being alive, filled with the vitality of existence.*
Neuroscience doesn’t capture the feeling of being human. It’s about neurochemical events responsible for this feeling, but it doesn’t capture the experience of being alive, sad, happy, depressed, in love, etc. The question is how much this matters, and how the neurological explanation can be made useful without diminishing the experience of life.
Thus, we now know that psychiatric illnesses, like neurological disorders, arise from abnormalities in the brain. (p 41)
It’s not true, at least not when stated like this. These “abnormalities,” which exist, may be the brain’s normal reaction to an abnormal environment. What goes on in the brain is caused by the environment we live in, not just autonomous neurochemical events in the brain itself. Everything I experience changes my brain. But that doesn’t mean that all, or even most, psychiatric diseases arise from abnormalities in the brain. Some do, some don’t, and many are a mix. Besides, the term “arise” is too vague.
Kandel talks about PTSD at some length, and I’ll get to that shortly. His treatment of the topic is disturbing, but the scope of the book is broader and worth considering.
A “new scientific humanism”?
As research into the brain and mind advances, it appears increasingly likely that there are actually no profound differences between neurological and psychiatric illnesses and that as we understand them better more and more similarities will emerge. (p 43)
This convergence will contribute to the new, scientific humanism. (p 43)
I have only a scant idea of what Kandel means by “the new scientific humanism.” It would have helped had he defined “humanism” to begin with. I think he means that experience still matters, particularly one’s own experience of events such as depression.
Depression
Until quite recently, says Kandel,
psychiatric disorders were notoriously difficult to trace to particular regions in the brain. But today’s brain-imaging technologies, specifically PET and functional MRI have enabled scientists to identify at least some components of the neural circuit responsible for depression . . . Scientists have come to understand which patterns of neural activity are altered and can examine the effects of antidepressant drugs and psychotherapy on those abnormal patterns of activity. (p 87)
Scientists have suggested that increased activity of the amygdala may account for the hopelessness, sadness, and mental anguish that people with depression feel. Imaging has also found that, like many other disorders, depression may result in fewer and smaller synapses in the hippocampus. (p 89)
At the same time, Kandel understands that depression is so overwhelming that the sufferer must learn to make sense of the brain-based experience, even (or especially) when the suffering is eased.
In her book An Unquiet Mind, she [Kay Redfield Jamison] writes that psychotherapy “makes some sense of the confusion, reins in the terrifying thoughts and feelings, returns some control and hope and possibility of learning from it all. Pills cannot, do not, ease one back into reality.” (p 99)
Andrew Solomon, a researcher on depression who himself became very depressed agrees.
Once you have been depressed, and particularly once you have allowed medication to reshape your mental states, you need to understand who you are at the most fundamental level,
The fashion for biological explanations of depression seems to miss the fact that chemistry has a different vocabulary for a set of phenomena that can also be described psychodynamically.
Neither our pharmacology nor our analytic insight is advanced enough to do all the work; to approach the problem of depression from both angles is to figure out not only how to recover, but also how to live the life that must follow on recovery. (pp 99-100)
This must be Kandel’s “new scientific humanism,” and it’s not all wrong, especially regarding depression. And with depression, one has some idea of what it would look like. As better drugs and other treatments for depression are developed, these therapies need to be accompanied by psychotherapy, lest changed brains confuse and disorient old selves. Recovery from depression should be an experience that we can make sense of, not just something that happens to us.
Trouble is, this all falls apart with PTSD
Something about PTSD leads Kandel to leave the new humanism behind. I believe it is the fact that PTSD is so clearly the result of environmental intrusion into the self. With the term “self” I mean our experience of ongoing personal identity in relation to others. Whether it’s experienced in war, a terrible accident, rape, or chronic abuse, PTSD is the result of the intrusion of the external world into the body-mind. That’s how the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM 5tr) defines the disorder (309.81). The International Classification of Diseases (ICD 11), the DSM for the rest of the world, makes the same point: trauma is intrusion. **
Judith Herman, a psychiatrist whose Trauma and Recovery first brought the concept of PTSD to a wider public, is committed to the dose-response curve. The more severe and long-lasting the trauma, the worse the PTSD.
The most powerful determinant of psychological harm is the character of the traumatic event itself. Individual personality characteristics count for little in the face of overwhelming events. There is a simple, direct relationship between the severity of the trauma and its psychological impact. (p 85)
PTSD is defined by the external force that causes it. That was true in its first appearance in DSM III in 1990, and it remains an essential part of the diagnosis. The diagnosis of PTSD was a response to the Vietnam War, in which normal people were placed in abnormal situations that threatened their bodily and psychological integrity. PTSD was as much a social and cultural diagnosis as it was an individual one. Or as Herman puts it, “without the context of a political movement, it has never been possible to advance the study of psychological trauma.” (p 50). That’s not strictly true. What is true is that the study of trauma follows broad social trends.
If Herman would turn PTSD into a social disease, Kandel would turn it into a genetic one, abandoning the dose-response curve for a genetic explanation.
If one hundred people were exposed to the same traumatic event, about four men and ten women would develop the disorder. (Kandel, p 255)
The difference is genetic susceptibility. Or at least that’s what Kandel assumes. In the case of schizophrenia, more than two hundred areas of the genome, and at least ten genes are involved.*** No one has identified a genetic pattern associated with PTSD.****
Kandel just assumes that because different people respond differently, the reason must be genetic.
These findings indicate that one or more genes predispose people to the disorder, and this may also explain why PTSD so often occurs with other psychiatric disorders: they may share some of the same genes. (p 255)
That there might be subtle variations in the experience of “the same” trauma, and unrecognized sources of support for some people but not others, does not enter into Kandel’s picture. How people experience trauma is in the details. Furthermore, who says that PTSD often occurs with other psychiatric disorders? Kandel offers no evidence, what evidence there is appears weak, and co-occurrence is defined over a lifetime (Foa). Are PTSD at 20, depression at 70, comorbid? No.
Therapy for PTSD
The therapies Kandel recommends for PTSD are cognitive behavioral therapy, including prolonged exposure therapy and virtual reality exposure therapy (p 256). Not only are these some of the worst therapies around, but they are popular for the wrong reasons: because they are short, cheap, and can be easily “manualized,” so technicians with limited training can use them.
Nor do they speak to an important point recognized by Kandel. Trauma is experienced in and through the body. We feel it before we know it, and we know it in our bodies. Body-work, including such simple therapies as massage, yoga, and somatic relaxation rituals, the therapies endorsed by Bessel van der Kolk, are a better bet, and no more expensive. Combining body-work with talk therapy, recognizing that the process takes time and skilled practitioners, is probably the best bet.
Conclusion
At points throughout the book, Kandel delivers on what he calls the “new scientific humanism,” if we define the term as recognizing that changing the brain is not enough. People must learn how to live with themselves, including selves changed by chemical means. Some people may not like these new selves and stop taking drugs. But in his discussion of PTSD the new humanism is nowhere to be found. I believe this is because the diagnosis of PTSD requires an identifiable external stressor. Without an external source of trauma, there can be no diagnosis of PTSD.
Kandel is reacting, I believe, to the tendency of some, like Herman, to emphasize the social and political origins of PTSD. For if PTSD is a social disease, then a neuropsychological framework is fundamentally incomplete, even misleading. PTSD should continue to be subject to neuroscientific investigation and understanding, but the larger context for understanding PTSD should be that of a social and psychological disorder, one in which suffering and its cause are, or can become, comprehensible to its victims.
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* The psychoanalyst D. W. Winnicott emphasizes that not peace of mind, but feeling alive, is the goal of mental health. Nietzsche too embraces aliveness as the measure of humanity, though of course, he defines this feeling differently.
** The International Classification of Diseases (ICD-11) seems to no longer require an identifiable external trauma in the case of children, though this remains unclear because C-PTSD (or developmental trauma disorder) must first fulfill the requirements of a diagnosis of PTSD, which includes an external source of trauma (code 6B41).
*** https://www.genengnews.com/topics/omics/schizophrenia-genes-and-loci-identified-through-landmark-studies/. Two of the genes are GRIN2A and GRIA3.
****Kandel documents some claims thoroughly, others not at all. He says that one gene that regulates our response to stress has been identified, and this change heightens the risk of developing PTSD in response to traumatic stress in adulthood (p 255). Well, which gene? Where? Anyone who knows anything about genetic influences on the brain, and that certainly includes Kandel, knows that genes operate in concert with other genes as well as the environment to produce complex emotional states such as PTSD.
References
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th edition. American Psychiatric Publishing, 2013. The text revision (TR) was published in 2022. It includes few changes.
Edna Foa, Effective Treatments for PTSD, 2nd edition, 606-613. Guilford Press, 2009.
International Classification of Diseases, Eleventh Revision (ICD-11), World Health Organization (WHO) 2019/2021 https://icd.who.int/browse11.
Kay Redfield Jamison, An Unquiet Mind: A Memoir of Moods and Madness. Vintage, 1996.
Eric R. Kandel, The Disordered Mind: What Unusual Brains Tell Us About Ourselves. Farrar, Straus and Giroux, 2018.
Bessel van der Kolk, The Body Keeps the Score. Penguin, 2015.
Friedrich Nietzsche, The Gay Science, # 231.
Andrew Solomon, Noonday Demon: An Atlas of Depression. Scribner, 2015.
D. W. Winnicott, “Aggression in Relation to Emotional Development,” in Collected Papers. Basic Books, 1958.
