Genetics and mental illness

I can buy into genetics playing a part in mental illness. What i don't buy into is how psychiatry plays 'fast and loose with the genetics factor.

For example schizophrenia is seen as a 'genetic disorder' with heritability rates of around 40-50%
and yet borderline personality disorder is seen as being due to 'learned behaviour' with heritability rates ranging from 39-68%.(Using Google search for 'borderline personality' and heritability)

One is shoved on axis 1 and the other on axis 2. This is clearly nonsensical and illustrates the bias of those working within the psychiatric profession and the effect of diagnostic turf wars between psychiatrists and psychologists.

A lot of the 'Is it genetic or not?'/axis 1 or 2' seem also to be tied in with whether meds work or not.
The distinction being that meds work for schizophrenia and are not that effective for something like borderline PD.

Two problems here

(1) Meds for sz don't work as effectively as they are trumpeted to work.
Several studies have come out saying that the atypicals aren't really any more effective for sz than the first generation antipsychotics . neither the conventional or atypicals are overly effective when it comes to the cognitive problems that are reckoned to be the most disabling aspect of schizophrenia.

(2)As stated here

"Officially recognized in 1980 by the psychiatric community, borderline personality disorder is at least two decades behind in research, treatment options and education compared to other serious mental illnesses. Congressional Resolution, H. Res. 1005, is awaiting final action to designate May as Borderline Personality Disorder Awareness Month."

Schizophrenia under the old name of 'Dementia Praecox' was first identified as a discreet mental illness by Emile Krapelinin in 1887. 121 years on and we still don't have a totally effective medication for schizophrenia though there are meds that work to some extend.[The first of these coming into regular use in the mid 50s(68 odd years after sz was first identified as a 'discreet mental illness')]

It is therefore the height of folly to dismiss borderline PD in terms of being not amenable to pharmacotherapy and therefore by derault 'non genetic' after only being officially in existence for 28 years.

Ditto re how long manic depression/bipolar was around before lithium proved effective for certain types of the illness ie the so called 'classical' type.

I like this quote from Mcmanweb http://www.mcmanweb.com/borderline.html

"Unexpectedly, the first borderline discussion there occurred during question time at a packed luncheon symposium on bipolar II. One of the presenters, Terence Ketter MD of Stanford, happened to say that as opposed to bipolar disorder, which is about MOOD lability (volatility), borderline personality disorder is about EMOTIONAL lability. As soon as they develop an emotion stabilizer (analogous to a mood stabilizer), he said, borderline personality disorder will become an Axis I disorder rather than Axis II.

Axis I disorders, as categorized by the DSM-IV, include bipolar disorder, depression, anxiety, schizophrenia, and other illnesses regarded as biologically-based and treatable with medications. Axis II disorders tend to get a lot less respect. As well as borderline personality disorder, these include antisocial personality disorder, narcissistic personality disorder, and a host of behaviors that impede personal and social function."

I think if the psychiatric profession were more consistent and honest when it comes to the genetics angle people would accept it more.

As it is as an intelligent person with a mental illness i get increasingly pissed off with the bull %#@&#! that stems from those opposed to psychiatry ie the anti psychiatry mob and the bull %#@&#! that stems from those working in the psychiatric profession.
Whichever way you flip the coin you get disingenuity/disinformation/and hyperbole in liberal measures.
Psychiatry over here is increasingly being hijacked as a vehicle for pushing government social policy rather than meeting the varying individual needs of the mentally ill.

Also i'm browned off with the long running turf war between psychiatrists and psychologists who seem to be content to see who can intellectually outdo one another at the expense of the clients they are supposed to be helping.

Good post, very informative and well spoken. I have always believed that western medicine for all its technical ability fails to treat the "whole person" and focuses too much on treating the illness.

I feel your pain, perhaps we all need to look at eastern practices realtive to mental disorders, I think by adjusting chi flow so that it is properly balanced, many of the symptoms that people experiance here may be greatly reduced.

It is difficult to overcome genetic handicaps, but with persistance, patience and an individualized treatment regimen it can be done.

I certainly agree that the professions have a LONG way to go.

Another area to consider is that all of the disorders may have different origins, or multiple origins. For instance PTSD - 2 men in the same battle, one comes out with PTSD, one without. In that situation there are 3 things to consider - the impact of the trauma, their genetics, and the environment they were raised in.

IMO, eventually BPD will be moved to AXIS I where it belongs. It's not an intractable personality type. An invalidating childhood environemnt is at best a neglectful one. These people were injured, need long term treatment and can improve.

Slippers

ALL of us, "mentally ill" or not, have our own genetic inheritance. Of course it plays a PART in any illness. My brothers and I have distinctly different personalities, partly due most probably to genetic factors. I think those differences also played a part in how we were treated as children and how we reacted to that treatment.

I have three nieces; their mother said they were different in the womb. I have two cats, brother and sister. They have distinctly different personalities.

I feel that the assignment of any mental disorder to any specific gene is bogus. In spite of constantly recurring news headlines identifying such genes.

The older I get the more I see the mental illness my mother had in me. I think that "normal" for me was mental illness. I had nothing to judge that the way we lived was anything but acceptable.

The good old nature vs nurture debate. My mother was most definitely depressed. My father was an alcoholic. So did I become a depressed alcholic due to heredity or is it a learned behaviour?

I do know that my depression responds well to medical treatment ie drugs, so I do think there's a genetic component to it. In the case of alcoholism I know there have been brain imaging studies showing the differences in response to different stimuli between alcoholics and non-alcoholics. I also know that I've repeated just about every behavioural pattern I saw in my father and so my treatment for alcholism has required both medical and psycho/social intervention. I take medication to help control the cravings but I'm also in therapy to learn new and better coping mechanisms.

I think in the case of mental illness it's impossible to clearly delineate what is genetic vs what is learned maladaptive coping.

---spltiimage

My psychologist sent me to my psychiatrist. Neither needed a label to treat me. But I can see where you're coming from.

I have been a client of services since I was 5 years old and it gets confusing with all the paperwork and different diagnoses and varying opinions of all the different interns and such that treat medicare patients like me.

I have come to know that I can not afford my mental health services and have lost some faith in their integrity and effectiveness.

I am sorry if that seems mean.

Hey. I enjoyed your post :-)

>... schizophrenia is seen as a 'genetic disorder' with heritability rates of around 40-50%

Paul Griffiths (who works in science communications) has a lot to say about these kinds of statistics. In particular, there are three different working concepts of the gene that different scientists work with. The above kinds of statistic comes from conflating all of those different notions - lumping them all together into something called the 'gene' that seems to have (in virtue of the lumping) this amazing heritability factor. One could do a similar thing by lumping together all kinds of environment factors (if one doesn't get adequate nutrition then genes can't express - it is as simple as that).

Acquiring a natural language (the language your caregivers speak) has a heritability rate up in the 90's, I'd imagine. I don't think anybody considers speaking a natural language to be genetically heritable, however. And yet... Why not? Our success in finding the genetic basis for language is comperable to our success in finding the genetic basis for schizophrenia.

I think the main (practical rather than justificatory) reason for the axis 1 and axis 2 distinction comes down to the (practical rather than justified) difference between psychiatry (as a field) and clinical psychology (as a field). What justifies psychiatry being a branch of medicine? The practice of prescribing medication. What makes clinical psychology distinct from psychiatry? Psychometrics and therapy (especially cognitive behavior therapy and modifications of that).

Borderline personality used to be a name given to people who were treatment resistent from the perspective of psychiatry. The medication might help with symptoms a little... But it doesn't help as much as it seems to for other more paradigmatic psychiatric disturbance such as psychosis and extreme mania and extreme depression (though this is controversial it is standardly accepted in psychiatry).

There is a little more to the axis 1 / axis 2 distinction. Mental retardation is an axis 2 disorder - remember, but there are many genetic reasons for mental retardation (downs syndrome and the like). The genetic basis for some forms of mental retardation is far better understood than the genetic basis for paradigmatic axis 1 conditions.

> A lot of the 'Is it genetic or not?'/axis 1 or 2' seem also to be tied in with whether meds work or not.

> Several studies have come out saying that the atypicals aren't really any more effective for sz than the first generation antipsychotics .

They were never thought to be more effective. They were marketed as a breakthrough for the simple reason that the side-effects were thought to be less severe. The breakthrough is that (since we haven't had time to see the long term side effects) the development of tardive dyskinesia (parkinsonian like movement disorder) and tardive dementia (kind of early onset dementia) seems to be lower. Similarly for anti-depressants. They aren't thought to be more effective than MAOI's - but they aren't potentially lethal if one doesn't stick to a restrictive diet. Psychiatric medications simply haven't become more effective - old medications are replaced by newer medications simply in virtue of the side effects being considered preferable.

> "Officially recognized in 1980 by the psychiatric community, borderline personality disorder is at least two decades behind in research, treatment options and education compared to other serious mental illnesses.

Though the term was around well before that. Has origins in both medical psychiatry and traditional psychoanalysis. The DSM III had many many many more disorders than the previous manual (the majority of mental disorders weren't in the DSM II) and the DSM was the first attempt at an a-theoretic description of symptom clusters.

> As it is as an intelligent person with a mental illness i get increasingly pissed off with the bull %#@&#! that stems from those opposed to psychiatry ie the anti psychiatry mob

Forget about Tom Cruise. He is an actor and not an authority on either psychiatry or anti-psychiatry. Forget about the scientologists. They believe that UFO's gave us disorders (though not mental disorder apparently). They are not an authority on either psychiatry or anti-psychiatry. Forget about psychiatrists characterizations of the anti-psychiatry movement. They (almost willfully) mischaracterize their views. Try reading Szasz or Laing to come to grips with the issues that they have with psychiatry. They have many terrific points to make - points that psychiatry needs to take on board. For example... The role of social factors in the production and maintenence of mental disorder.

> Psychiatry over here is increasingly being hijacked as a vehicle for pushing government social policy rather than meeting the varying individual needs of the mentally ill.

Yep. It has been that for a long time. Did you know that homosexuality was taken out of the DSM in response to LOBBY GROUP pressure? PTSD was included as a result of LOBBY GROUP pressure? Addiction will similarly be either included or not included as a result of LOBBY GROUP pressure. They ad hoc pick the science that seems to justify their view. But that is the only sense in which they 'defer' to science (which is to say that the APA is driven more by political considerations than scientific considerations). It has always been that way and it probably always will be.

So... Don't underestimate how much the APA and psychiatry thinks they need the pharmaceutical industry to justify their place within the medical sciences. And given that is the case don't underestimate how much the development of medications that seem effective is a significant driving force in what mental disorders are considered the legitimate subject matter of psychiatry.

Clinical psychologists have much more invested in personality disorders as they have much more invested in personality (social psychology) and psychometrics for assessing personalitly. They don't prescribe, however, so we can expect treatments to consist in therapy.

> Also i'm browned off with the long running turf war between psychiatrists and psychologists who seem to be content to see who can intellectually outdo one another at the expense of the clients they are supposed to be helping.

No %#@&#!. Much as people go on about the bio-psycho-social model there is no theoretically sophisticated account of how these factors are supposed to interrelate with none being fundamental. Since there isn't a good account there is the suspicion (all round) that genetics/neurology really is fundamental and that sciences that focus on those factors are somehow 'better' and that there is where the significant advances are supposed to come from.

There is a lot of professional jealousy from psychologists because the psychiatric association gets to make the authorative diagnostics manual for mental disorder. There is a lot of professional jealousy from psychologists who think that genetics / neurology is where it is at after all - so they want to prescribe meds too.

by the way...

research into the genetic basis of mental disorders is highly problematic for a number of reasons...

firstly... inter-rater reliability is poor. that means that if you video-taped a person and asked clinicians to assess what mental disorder they had then there would be a GREAT DEAL of disagreement by the clinicians as to what disorder the person had.

the genetic research into the basis of schizophrenia relies on the people being diagnosed with it actually having it and the people who aren't diagnosed with it actually not having it.

the place to start with the genetic research is with linkage analysis. basically... take a family tree and look at the individuals on the family tree that are affected with the condition. this allows you to say whether it has a dominant genetic basis or a recessive genetic basis or whatever. basically... linkage analysis reveals that the genetic basis for schizophrenia isn't anywhere near as simple as that.

so people posit some complicated combinations of genes (where by genes now what is meant is values on a particular location of the chromosome).

probably the best study that has been done is the stuff that has focused on analyzing data from the icelandic genome project. how come? because they have kept extensive health records for every member of the population including diagnoses and... their genome.

so... great data to try and find the genetic basis.

the BEST candidate for the genetic basis of schizophrenia that emerged from that project was 3 particular values (in a certain combination) on 3 distinct places on the genome. sometimes 'genetic' is used to mean that (rather than mere location). so... what are the chances? About 15 percent of people without schizophrenia have those 3 values in that combination on those three places on their genome. About 7% of people with schizophrenia had those 3 values in that combination on those three places on their genome.

We need to remember the diagnosing bias in that you are much more likely to be diagnosed with schizophrenia if you have a family history because firstly, you are more likely to come to medical attention in virtue of your family history and because secondly, clinicians are more likely to diagnose you with schizophrenia if you have a family history BECAUSE CLINICIANS ANTECEDENTLY BELIVE THAT SCHIZOPHRENIA IS HERITABLE. If you had the same person present with the same symptoms and the clinician was told that bi-polar rather than schizophrenia was in your family history THEY WOULD MORE LIKELY DIAGNOSE YOU WITH BI-POLAR.

Another problem... The genetic basis of the icelandic population is very homogenious (read in-bred). That means that they aren't at all a representative genetic sample of human beings in general, and that means that it is highly questionable that those three values on those three loci have ANYTHING AT ALL TO DO WITH SCHIZOHPRENIA IN OTHER POPULATIONS. And remember... That even with that homogenious genetic sample of the population the correlation between those three values on those three gene loci were BARELY SIGNIFICANT.

And that... Seems to be about the best we can do.
I have to say that I have no faith whatsoever in their being any better genetic basis to be found.

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alexandra_k said:


Though the term was around well before that. Has origins in both medical psychiatry and traditional psychoanalysis.

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As far as i am aware those who were originally dxed as ' borderline' were seen as having an illness that had a schizophrenic tinge to it and was seen as being at the borderline between neurosis and psychosis.
There were i believe several different terms used as well as 'borderline personality' such as Hoch and Polatin's(?) pseudoneurotic schizophrenia, ambulatory schizophrenia ,as if personality etc.

By current classification a number of those who fitted the then description for borderline/pseudoneurotic etc i believe would be classified as 'schizotypal'.

I believe that because of the way borderline and schizotypal were defined in the dsm 3(?) there was considerable diagnostic overlap between the two ie a sizeable number of people were seen as meeting the criteria for both diagnoses.

Definitions were then revised in an attempt to better delineate(? i hope that's the right word) the two disorders.

Nowadays schizotypal is seen as a 'schizophrenia spectrum' disorder whereas with 'borderline' the debate centres around how much it does or doesn't belong to the 'bipolar spectrum'.
The likes of Hagop Akiskal have pinned their colours quite firmly to the belief that borderline personality disorder belongs within the bipolar spectrum -( a rapid cycling/atypical variant of bipolar?) and have put their case quite eloquently and persuasively.

For example.

http://www.blackwell-synergy.com/doi....x?cookieSet=1
http://www.medscape.com/viewarticle/457151
http://tinyurl.com/393at9

Perugi G, Akiskal HS: Are Bipolar II, Atypical Depression, and Borderline Personality overlapping manifestations of a common cyclothymic-sensitive diathesis?

There was the 'borderline' between neurotic and psychotic thing. Even those terms aren't used in the official classification anymore I think they still persist in the conceptualization of quite a few psychiatrists.

The thought there was that the functional disturbance of people with traditional psychiatric disturbance (florid delusions and hallucinations, very severe depression, and severe mania) seemed more severe than people with neurosis. People with neurosis benefited from therapy whereas medication seemed to be all that helped with the traditional psychiatric disturbance. But then there were these people who seemed part way between... They would mostly function normally but they could deteriorate with episodes (from a few hours to a few days). Borderline personality...

Schizotypal was part of that, too. And narcissistic personality disorder is considered a 'borderline condition' (part way to delusions of grandeur and / or paranoia I guess). There was this idea that borderline conditions were often found when they went searching out family tree data. They wanted schizophrenia to be heritable but some of the releatives simply were below threshold ;-)

Check out hysteria, hysterical personality disorder, hysteriod personality disorder and the like. There are origins there, too.

> I believe that because of the way borderline and schizotypal were defined in the dsm 3(?) there was considerable diagnostic overlap between the two ie a sizeable number of people were seen as meeting the criteria for both diagnoses.

I'm not sure about that. I'd love to get a hold of (my own) copy of the DSM III and DSM III-TR. I know someone who has a copy of the DSM II. Apparently that one is worth a bit of money these days...

> Nowadays schizotypal is seen as a 'schizophrenia spectrum' disorder whereas with 'borderline' the debate centres around how much it does or doesn't belong to the 'bipolar spectrum'.

Yeah. It is odd, that. I have difficulty with the 'mood disorder' and 'psychotic disorder' distinction. While Kraeplin thought that his observations justified the distinction later research has called it into question. In particular, the number of people with 'schizo-affective' (who seem to fall somewhere between the two) problematizes the current distinction. I think that one unfortunate consequence of seeing borderline as mood and schizotypal as psychotic is that clinician's don't consider borderline personality disorder often occurs with avoidant personality disorder (which it does). avoidance... seems much more schiotypal. The presence of transient delusions for borderline personality similarly caused quite a disturbance...

Personally... I don't think that mental disorders come in different kinds in quite the way that the DSM supposes that they do. I do wish they would trash them in favor of assessing the presence or absence of symptoms...

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alexandra_k said:
. But then there were these people who seemed part way between... They would mostly function normally but they could deteriorate with episodes (from a few hours to a few days). Borderline personality...

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For me such 'deterioration' tends to occur when stress levels get too much. It can be quite an acute and dramatic process.
For example can i go fairly quickly from being calm to being in rant and rave mode where my conversation is irrational, highly accusatory,paranoiacally excitable etc .Sometimes especially if the level of stress is maintained for long enough this can then evolve into what i call as a layman a 'after the mental fever has broken' state involving depersonalisation and derealisation.
At other times the stress can induce a somatic reaction which manifests in a short lived flu like reaction'

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alexandra_k said:
Yeah. It is odd, that. I have difficulty with the 'mood disorder' and 'psychotic disorder' distinction. While Kraeplin thought that his observations justified the distinction later research has called it into question. In particular, the number of people with 'schizo-affective' (who seem to fall somewhere between the two) problematizes the current distinction. I think that one unfortunate consequence of seeing borderline as mood and schizotypal as psychotic is that clinician's don't consider borderline personality disorder often occurs with avoidant personality disorder (which it does). avoidance... seems much more schiotypal. The presence of transient delusions for borderline personality similarly caused quite a disturbance...

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I read somewhere(a book but i can't remember the name of the author-? Bentall) that many studies of 'true breeding' meant to lend credence to the Kraepelinian dichotomy have been compromised by what is termed the 'fallacy of the excluded middle' ie excluding those who do not fit the classical picture of bipolar 1 or sz.

Also it said that using discriminant functional analysis there were indications of a continuum rather than two separate illnesses and that finding a neat dividing line between bipolar and sz symptoms had proved elusive

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alexandra_k said:
Personally... I don't think that mental disorders come in different kinds in quite the way that the DSM supposes that they do. I do wish they would trash them in favor of assessing the presence or absence of symptoms...

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I guess i favour a more dimensional approach than the current categorical approach of the DSM .
In my case i have had a smorgasbord of dx including schizophrenia, schizophrenia with disorder of gender identity ,schizophrenia with personality disorder,schizoaffective mixed type,bipolar, and currently stands at Personality disorder NOS qualified by comments such as 'with emotional and explosive traits' 'consisting of sensitive and explosive traits' 'mainly consisting of sensitive,compulsive,emotional,unstable,and impulsive behaviour'.

Then of course there's been the unofficial musings of various pdocs ie 'dependent personality disorder with probably some histrionic traits '. 'very dependant narcissistic disorder' and not forgetting years ago the very old fashioned 'nervous debility'.

My symptoms don't seem to neatly and conveniently fit into the dsm boxes
in that i have varying degrees of so called mood symptoms,emotion based symptoms, anxiety of a social/avoidant and also generalised nature plus some symptoms which could be seen as slightly schizophrenic in nature -paranoia, bouts of quite obsessively bizarre thoughts often of a sexual nature and last but not least cognitive problems.
Although deemed by several pdocs over the years as highly intelligent there is a marked verbal > performance with quite poor visuospatial skills and executive functioning problems involving organising and planning.

Hey. Yeah, I don't deal with stress terribly well either. I don't think that many people tend to... But I guess it affects me more than most.

Did you read 'Madness Explained' by Bentall? I like a lot of what he has to say about the dimensionality of mental disorder. Liked it very much.

Here are some other terms relevant to the history of borderline personality: hysteria, histrionic, hysteriod personality.

Know what the most prevalent diagnosis is? NOS. More people meet criteria for a mental disorder 'not otherwise specified' than meet criteria for any of the standard diagnoses. Kinda shows something of the inadequacy of the present categories...

It is funny how theory laden even descriptions of symptoms seem to be...