What is a Brain Disorder?

• There is no definite idea of what constitutes a brain disorder.
• We adopt the decision of the National Institute of Mental Health to use the term “brain disorder” when we refer to conditions which cause impairing or debilitating behavior.
• Current ideas of brain disorders are based on ideas rather than objective evidence.
• In the United States, brain disorders are defined in the Diagnostic and Statistical Manual (DSM). This provides the basis for insurance coverage, school accommodations and government services.
• No major research breakthroughs have occurred under the current diagnostic classification system.
• New research tells us that our brains function in a way that is at odds with how mental disorders are currently conceptualized.
• A problem in any part of the brain is likely to produce a wide variety of behavioral changes rather than just a group of similar ones.
• In the short run, the inevitable transition into a more accurate, evidence based way of measuring and treating impairments related to brain function will add more chaos to an already confusing situation
• Eventually we will end up with a system of diagnosis and treatment that is reliable and targeted because the cause and characteristics of the condition will be known and objective.

It’s Not Black and White

Atypical, problematic or unexplainable behavior has always been present. For most of time, it has been considered onerous, shameful and/or willful. In some cultures it has been regarded as mystical and special. Today, in western culture,  there is growing acceptance that this type of behavior is a direct product of brain function and that it deserves the same type of objective consideration that physical problems receive. Nevertheless, underneath this broad statement, many questions and opinions remain.

At JBRF, we consider a brain disorder to be a condition in which brain activity produces behavior which causes a person to have a significantly reduced ability to function well in his or her life or to pose a threat to his/her well being and/or the well being of others. While it may be easy to recognize when someone is seriously affected in this way, it is a debate-able and fuzzy line along a spectrum of wellness that determines whether or not there is a diagnosable disorder.  There will never be absolute answers to these questions, but science has struggled to bring us closer to them.

Since behaviors themselves and the cultures  in which they are measured have such a wide range of variability, acceptability, and adaptability, it is very hard to place an exact definition on what is healthy, or healthy enough, and what represents a pathological condition which needs therapeutic and/or medical attention. Many people would argue that most conditions which are diagnosed as disorders are simply points-on-a-spectrum of varying abilities and individual affects.

When these conditions are seen as disorders, there is not a  single opinion about what they should be called. Should we use the name mental illness, brain disorder, neurological condition or something else?

These days, the most commonly used term is “mental disorder”. Indeed, this country’s manual from which all mental health diagnoses are made is called the Diagnostic and Statistical Manual of Mental Disorders (DSM).

At JBRF, we have adopted the recent decision made by the National Institute of Mental Health (NIMH) to refer to them as “brain disorders”. We feel it is appropriate to associate the condition with the organ that creates it; the brain. The term “mental disorder” brings in the notion of the mind… and that suggests a level above biology. While we could consider using the term “neurological disorder”, NIMH reserves this term for conditions in which actual damage has occurred to the brain. So we will respect that differentiation.

What is a Brain Disorder in the US today?

You are probably familiar with many of the classifications of disorders listed in the DSM: depression, bipolar disorder, attention deficit disorder, separation anxiety, obsessive compulsive disorder etc. These and other classifications provide the diagnoses recognized by educational systems, medical and social services, and insurance. Over the 30+ years of the DSM’s existence, experts periodically re-convene to incorporate new knowledge into the manual; classifications which may have seemed quite plausible at one time may be eliminated, others may be changed, and new classifications may appear. The next version of the DSM; DSM 5, is due out in May of 2013. One of the most notable changes in it affects the diagnosis of bipolar disorder as it has been applied to children. For more about that, click here.

There has been quite a degree of controversy over the changes proposed by the new manual. This is to be expected in a system which is still based on concepts rather than proof. To read a commentary by the Director of the NIMH regarding DSM5, click Research Domains, Director’s Blog 3/13. To read a New York Times editorial on the state of diagnoses and DSM5 click here.

What will a brain disorder be tomorrow?

Advances in genetics, neuroimaging, and neurology have made possible substantial progress in the knowledge of how the brain creates behavior. Contrary to popular ideas, behaviors like mania and depression are not created by distinct parts of the brain, the simple absence of specific chemicals or mutations of specific genes. Instead, our brains function through complex but efficient sets of functional networks which stretch across the brain and even through the body, affecting and being effected by other networks. From this more complex perspective, it is easy to understand how a single dysfunction could produce a broad range of downstream symptoms and behavioral changes rather than just a group of similar behavioral symptoms as in depression or OCD.

The field of psychiatry has begun to enter a phase of transition.  While the current classification system continues to be recognized and relied upon, new information is chipping away it its legitimacy. What is considered a “mental disorder” today might vanish from our diagnostic language tomorrow.

The National Institute of Mental Health has recently announced a comprehensive new initiative called Research Domain Criteria (RDoC) the mission of which is to establish a foundation of knowledge that ranges from genes to behaviors.  Presumably this will lead to a new body of predictable diagnoses and treatments. (see Toward a New Classification Framework for Research on Mental Disorders).

Like most major transitions, this one will be slow and not without some resistance and a fair amount of confusion. There is much to be learned…an unlearned. Hopefully we will soon come to the point when we stop thinking of ourselves as existing from the neck down or from the neck up –but rather as the exquisitely connected and functioning whole beings that we are. In this future, the stigma that is today reserved for mental health will naturally dissolve and we will be able to take better care of ourselves.