Should mental illnesses be referred to as "brain diseases"?

I stumbled across an interesting article in The Behavior Therapist, published by the Association for Behavioral and Cognitive Therapies, titled On the Brain Disease Model of Mental Disorders, by Brett Deacon and James Lickel. The "brain disease" model holds that mental illnesses are biologically-based and are the result of underlying alterations in neurochemistry. I have used the terms somewhat interchangeably, and probably will continue to do so, although the semantics of the two terms are different.

In this article, the authors contend that the brain disease model has some drawbacks, namely:

We are concerned that the enthusiastic promotion of the brain disease model by NIMH and other prominent sources (e.g., National Alliance on Mental Illness, the pharmaceutical industry) has far outstripped the available scientific data and may actually be increasing the stigma associated with mental disorders.

For starters, they say, there are no diagnostic tests for mental illnesses based on abnormal brain circuitry. Secondly, although the acknowledgement that a mental illness is a brain disease decreases how much the sufferer blames him/herself, it also tends to make them view their situation as more hopeless. Furthermore, increases in our biological knowledge and understanding of mental illness have not yet resulted in better biological interventions.

...the intervening decades have not witnessed the expected advances in biological technology for diagnosing, preventing, treating, or eliminating common problems like mood and anxiety disorders.

...the notion that “mental disorders are brain disorders” represents an eliminative reductionistic perspective in which higher-level psychological processes such as thoughts, emotions, and behaviors are entirely explained by their putative biological causes. From this point of view, an association between biological variables and mental disorder symptoms may be interpreted as demonstrating the disease process that caused the disorder. This perspective leaves little room for the possibilities that apparent biological abnormalities might be the result of a mental disorder, a consequence of chronic psychotropic medication use (Leo & Cohen, 2003), confounded by affect-induced physiological changes during the biological test (Whiteside, Port, Deacon, & Abramowitz, 2006), or reflect a vulnerability for developing a mental disorder without directly causing it.

The authors do raise some important points, but many of the issues they raise have less to do with the brain disease model and more to do with our understanding of biology in general and the brain in particular.

Let's start by comparing neuroscience to physics. We've known from the time of Newton the forces that cause a planet to orbit a star, or a moon to orbit a planet. These rules have been the same for hundreds of years, rules that even today guide our ability to launch a satellite that enables me to Twitter on my Blackberry. Newton could have told us how to do it, but he wouldn't have been able to launch the satellite. Why? Technical difficulties. He simply didn't have the equipment and probably couldn't imagine the equipment. But that doesn't mean that his theories of gravity were wrong or that we were never going to send satellites into space.

Something similar is going on here. Just because we can't yet diagnose mental illness based on abnormalities in brain functioning doesn't mean that this differences aren't there. It means we can't measure them. Maybe we never will be able to measure them. But the evidence is pretty consistent in linking underlying neurochemistry to mental illness. The authors are right in pointing out that we don't know everything about these neural differences, and whether they are diagnostic, indicate increased risk, or are a scar from previous incidences of this mental illness. It's likely that a single brain scan looking at one single thing isn't going to be diagnostic of anything. Rarely does a single factor diagnose any disease, mental or otherwise. Usually, it's a combination of factors that lead us towards disease.

As much as we like to think of there being a "gene for" depression, bipolar disorder, eating disorders, schizophrenia, diabetes, obesity, cancer, that's just not how DNA works. It's not an on/off switch; rather, genetic risks function a lot like a dimmer switch. And determining how bright that light is also needs to account for the ambient light in the room, those environmental factors that interact with genes to help increase or decrease risk. If the room is dark, even a dim light will be obvious. At high noon, however, you might not even notice that the bulb is on.

We accept (however unwillingly) these biological complexities in illnesses like cancer and diabetes. There's a general understanding and acceptance that there will never be a "diabetes gene," that our treatments have improved over the past several decades, but we're still a long way from anything that could be called a "cure." That doesn't change the fact that diabetes is an endocrine disorder.

The other main issues that Deacon and Lickel raise has to do with an increase in the amount of hopelessness one feels when they are told that their illness is the result of biology. And perhaps the earth felt hopeless after they told it that it was no longer the center of the universe, but that doesn't make it any less true. Understanding science is a major issue in America, so it's no surprise that the more science-based explanations of mental illness have resulted in some misconceptions. Maybe it's because I have training as a biologist, but I found the knowledge that my eating disorder was the result of biology to be tremendously hopeful. I had plenty of insight, but I still wasn't getting better. I wasn't "choosing" recovery somehow. I thought my difficulties in recovery were my fault, rather than the result of a pernicious illness.

There is tremendous freedom in accepting the fact that, as far as ED biology goes, I'm f*cked. It's true. Dieting or even skipping a meal ends very, very badly for me. And if we're looking for treatment of mental illness to fundamentally change who we are as people, we're all f*cked. We can't do that. We don't know how to do that, and there's no reason that we should.

From a biological standpoint, my brain is high anxiety. I worry. A lot. I get depressed. A lot. Excessive exercise and starvation are strangely rewarding. There isn't much I can do about this. In fact, I've stopped trying. What I am doing, however, is learning how to live with my biology in the best way I know how.

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Cathy (UK) said...

Fantastic post (as usual) Carrie...

I agree 100% with your sentiments regarding the sense of relief that one might gain through knowing/believing that their illness (for me - anorexia nervosa) was underpinned by inherent/biological forces.

When I was diagnosed with anorexia nervosa, at age 12 (and from thereon...), I felt that my behaviours were controlled by some unconscious, almost alien-like force, and were out of my control. I obtained such relief and satisfaction from restricting food and exercising (the harder the better), despite these behaviours being counteractive to homeostasis. Moreover, this 'thing' in my mind 'instructed' me to behave in this self-destructive manner. This was the same 'thing' that had instructed me to arrange all my books and stuffed animals in order of size as a young child, and to clean my teeth exactly 4 times every night as a kid. I have ALWAYS had obsessions, complusions and rituals to relieve anxiety, and try as I might to fight them they don't go away.

On the basis that anorexia nervosa is neurobiological in origin - perhaps comparable to OCD, OCPD or autism - I disagree that we need to treat it with medication. I absolutely refuse to take medication... No, I am learning to accept myself as I am, to modify my lifestyle to avoid potent stressful triggers, and to learn to use alternative, self soothing behaviours to control my anxiety where possible.

For me, accepting the hypothesis that anorexia nervosa is biologically based (with inherent risk factors, but also starvation-induced) answered a lot of questions about why change was so difficult and scary. It didn't make me feel hopeless, but hopeful. It also helped me to recognise the importance of weight gain and preventing even inadvertent weight loss.

Sorry for the essay....

Susie said...

Very Interesting to read, especially as my GP told me to shift the blame from myself just yesterday. when i questioned why should i, because i did the damage to myself. she replied "why can it not be a disease?"

So your paragraph:

"Secondly, although the acknowledgement that a mental illness is a brain disease decreases how much the sufferer blames him/herself, it also tends to make them view their situation as more hopeless."

certainly rings true with me. But i'm not sure whether it made me feel more hopeless or learn that i need to learn to deal with my life and me as things are. I guess that depends how i'm feeling at the time, for instance in a depression like now, things seem hopeless.

And in someways with K, my GP trying to get me to accept that it may be biological, has stopped me looking for a reason & a cause for the depression. her words yesterday: "Lass, i don't know what happened to you when you were little or how much or this is within you - but no-one would chose this."

Sorry brain seems to have stop working right now, hope i got my point across somehow.

Anonymous said...

This whole article and post again leads me to wonder, can't we do both? Cant we acknowledge the neurobiology - the brain disease - AND the way that experience and culture play into it?

That's one reason that I still stick with the mental illness model. Calling eating disorders (or whatever mental illness is at hand) a "brain disease" only acknowledges the neurobiology. It only acknowledges a piece of the puzzle. An important piece, but a piece none the less. I prefer to use "mental illness" because that term can allow for the neurobiology as well as other factors that are often at play in the development of eating disorders.

Cathy (UK) said...

Sayhealth: I don't think that anyone would, or could suggest that EDs, or other mental illnesses occur solely because of (individual) neurobiology. These illnesses will always be expressed through our own personal experiences of living in whatever culture we live, our interpersonal experiences etc.

Sorry, I'm geing very 'gobby' today :D

Likewise, culture, interpersonal factors etc. may fuel existing ED behaviours in susceptible individuals. Because of the myriad of factors that come into play in triggering and sustaining EDs, treatment approaches must target all such factors where possible - and this will always require some element of an individual approach.

Although the behaviours of (e.g.) anorexia nervosa may be similar amongst all individuals diagnosed with the illness, the meaning of those behaviours to each individual many be very unique and personal.

Katy said...

Very interesting...

I really don't see how seeing mental illness as biologically based (though influenced/triggered by other factors) induces hopelessness. For me, understanding my depression as biological has been an immense relief--yeah, it sucks that it means I'm stuck with certain vulnerabilities, but it's NOT MY FAULT. Being able to remove the blame & stop kicking myself for not getting better has given me MORE hope. Instead of feeling like I'm failing & have to fundamentally change who I am (ideas that infuriated me because I always felt that I was doing my best & I LIKE who I am, dammit) I can see my depression as a part of my experience instead of a part of me. It's not who I am, it's an illness I have, & that's why thinking myself out of it/pushing through it/gaining insight did absolutely jack. It sucks that nothing's worked much so far, but it just means that I have to look for different solutions. If the issue wasn't my faulty biology, I'd be stuck pounding away at the same old BS, hating myself for not making progress & wanting to give up.

And maybe calling something a brain disease is reductive & on its face ignores other elements, but I think it's a hell of a lot better than what we have now. Our society has come to associate the term "mental illness" with moral weakness, whereas "disease" connotes a separate process that is outside one's control. (Though the health care debate makes it pretty clear that people get plenty of blame for CAUSING their illnesses...they just don't get blamed for the biological processes the diseases entail.)

Anyway...have I rambled enough? I don't know if what I said made much sense, but I feel pretty damn strongly that learning my depression had a biological basis is one of the best things that's ever happened to me!

Anonymous said...

It makes me crazy when I hear that scientists think they are getting closer to proclaiming that eating disorders are biological in nature. I have been struggling with anorexia and/or bulimia for over 25 years. I have been hospitalized for re-feeding numerous times, been in treatment programs, too. I am now with my third psychotherapist. We've been together for 10 years. Only now are things starting to improve.
If you do what my parents did - take a perfect little child/flower and water her/it with vinegar and then wonder what went wrong - do not even suggest to me that this agony is biological. I know it is not.

Jing said...

"Maybe it's because I have training as a biologist, but I found the knowledge that my eating disorder was the result of biology to be tremendously hopeful."
I think that a patient's feelings of hope/hopelessness in response to learning that their disease is bio based varies depending on their particular situation. If you're anorexic and you've been receiving psychobabble sessions without getting any better, then of course you're going to feel hopeful. But what about treatment resistant schizophrenia? A schizophrenia patient who responds well to medications might feel hopeful or empowered knowing that they have a biological condition. On the other hand, a schizophrenia patient who has tried every anti-psychotic in the book with minimal (or no) symptom relief (or with horrid side effects) will probably feel more hopeless in knowing that his illness is a result of biology. After all, he's been trying biologically based treatments and he still can't escape his horrible situation.

No, it has nothing to do with your training in biology and everything to do with your individual situation. You seem to think that people feel hopeless about their biologically based illnesses because they're too stupid or simple minded to understand the science behind it. An eating disorder is no cake walk but compared to other illnesses it is FAR from being a "hopeless" condition.

Please, stop acting all elitist about your "training as a biologist" and recognize that each person's situation is complex and different. People are a lot more complex than you give them credit for. Maybe some people try to pin their illnesses on environmental or psychosocial causes because those factors are easier to "control". Most people can control their environment to a certain degree (i.e. turning to family or friends for support, leaving a bad environment, etc). On the other hand you can't just change your genotype. Therefore, acknowledging the biological roots of an illness can create a sense of "doom" or a feeling of being out of control depending on what illness one has. It may be easier for you to feel hopeful with all that biology jazz because A) You have very viable treatment options like refeeding, which is known to be very effective for many ED patients and B) you have supportive parents who are willing to refeed you. Think about the people who aren't as lucky as you are. I have loved ones who've been destroyed by schizophrenia. It almost makes me wish that schizophrenia really was caused by bad parenting or something of that nature (even though I know it isn't).

I'm not saying that there isn't any value in the "brain disease" model. I agree that it can be empowering to learn that your illness is NOT your fault. In some ways it DOES reduce the stigma of mental illnesses. But there are negative aspects as well. Every coin has two sides. I agree with sayhealth's comment. "This whole article and post again leads me to wonder, can't we do both?"

Carrie Arnold said...


I'm sorry that your life was so difficult, and that your parents weren't as loving as they should have been. This couldn't have helped you in any way. However, I also think it's rather likely you had some underlying biological risk factors that also led to your eating disorder.


Say what you will about my "elitism," but I'm going to have to disagree. I was talking about my biology training in the context of why the brain disease model appealed to me, and why I would seek out such science-based explanations. I didn't see out biological explanations for my ED because I was some hoity-toity biologist trained at some elite Ivy League school (I wasn't; I was at a small midwestern liberal arts college), but because the other ways of thinking about eating disorders just didn't make sense. I was treated for years under the idea that there was something that happened to me that made me suddenly stop eating. And I tried and tried to find things, but none of it made sense to me. Even when I did find these things, it didn't make sense. I never felt my parents were over-controlling until after I got sick. And there's nothing like a dying kid to make a parent get a little overprotective. The more research I do, the more people I talk to and information I read, the more I am convinced that there is something fundamentally biological in the basis for eating disorders.

Context is important in any illness, whether it's eating disorders, cancer or diabetes. It's going to affect how people interpret their illness, what treatments they seek, or even if they seek treatment. There are always environmental factors to an illness, and the brain disease model never says that there aren't. What it does say is that if you don't have the biological risk factors, it's really unlikely that you're going to become ill. Cultural factors are relevant, but that's different than saying an eating disorder is about control, or wanting to look like a model. That's how we interpret these crazy symptoms of being terrified to eat, but that's not causative.

Yes, my parents are supportive, and I'm grateful for that. But that's not why I believe the brain disease model. I have come to agree with this model because such an overwhelming majority of the evidence says this is the case. I don't think it's wrong or elitist to trust science and randomized control trials. I think it's smart. We know that you can't recover from an eating disorder unless you reach a biologically appropriate weight and stop other ED behaviors like binge eating and purging. Supportive parents make that one hell of a lot easier, I won't deny it, but it needs to happen even if you were raised by Mommy Dearest. That doesn't change the fact that 80% of your risk for developing anorexia is genetic.

Katie said...

Knowing the degree of biological basis that mental illnesses have sometimes helps me and sometimes hinders, I think it really depends on my mood. For example, when I finally accepted that my anorexia was an illness, I used that to my advantage. I told myself over and over that all thoughts about food and weight were symptoms of an illness I was in recovery from and I refed myself with no help from my parents or the local EDU. I used the medical model to empower myself rather than to tell myself that having a biological problem meant I had no influence over the outcome. I think that can be a danger with anorexia, because when people are very unwell they do tend to look for excuses. In reality, although the illness was not my fault, recovery was still my responsibility.

I have a harder problem with the depression and anxiety I still suffer from, because it is unfortunately treatment resistant. I react extremely badly to antidepressants, they make me manic. In that case, thinking that my depression is biological makes me feel quite hopeless, because sometimes it feels like it turns me into a completely different person and I feel I have no control over it at all. I can't beat it by eating more, I just have to use the coping skills I do have and try to wait it out. DBT and CBT skills help, as do (healthy) exercise and distraction, but ultimately in recovery from anorexia I got a kick out of doing exactly what the disease wanted to stop me doing, whereas in recovery from depression there is very little I can actively do to change my brain chemistry.

I would also really like to see what would happen if psychiatrists started applying this research to their practise. I don't know what the general attitude towards mental illness is in the USA, but over here we are still largely treated as if we could get better if we wanted it enough. Obviously this is a bit of a stupid approach in anorexia, as most of the time it is impossible to 'want' to recover when you are very ill, so people get stuck at very low weights for years after the medical profession kind of give up on them after a few relapses. Even when I was in hospital for depression I saw a lot of people with bipolar disorder or severe depression being treated as if they were just being a huge pain in the ass and could pull themselves together if they wanted to. My psychiatrist was particularly hopeless, he quite frequently told me (and others) that I had a biological illness, but that nothing could be done about it (because of the medication problems) so I would just have to learn to live with it and stop being suicidal. Um. If only.

Basically, I totally agree that mental illnesses have a large biological component, but I am waiting hopefully for the day when that knowledge is used to improve treatment rather than either ignored or used to write people off.

Jing said...

I think you made some wonderful points about how knowledge of biology can be empowering in some cases or how it can feel hopeless in some cases. I also think you made a good point about how people can use biology as an excuse to escape responsibility.

I never said it was elitist to trust science. I don't know where you got that idea from. I just felt that you had a snotty attitude about it. Your comment about how "understanding science is a huge issue in America" did seem snotty. Ummm, I'm an American and I understand science, thank you very much. Why do you assume that everyone else is resistant to science? That's just snotty.

And also, your snarky analogy about the earth was very off putting. It sounded like you were dismissing the people who do feel hopeless about their illnesses. The reason I feel hopeless sometimes is not because I'm some hick who doesn't trust science. It's because I always wonder if I will be the next one to be hit by this terrible disease. I'm holding my breath until I turn 35 and then I should be home free. Oh, but I know that if I do get hit with this horrible disease that it will not be my fault so that should give me lots of hope right? Not! If you're living in a psych hospital and being injected with drugs like a lab rat and the doctors and nurses are looking at you with pity while your old friends are building careers, having kids, traveling to foreign countries and going to grad school, then the "Hey at least it's not my fault!" mantra kinda becomes a moot point. Wouldn't it be wonderful if schizophrenia wasn't biologically based? You can always escape a toxic environment but you can't escape your genes!

I don't care if you went to Redneck University or Harvard. A college education is an opportunity that many people never get. My sister's college plans were derailed by her illness. You make it sound like your small midwestern liberal arts college degree is nothing. You don't realize how lucky you are in so many aspects and it's driving me nuts.

Carrie Arnold said...


If you don't like me and my blog, then don't read it. I doubt we're going to agree on this subject, and I don't think any further debate on this is going to be good for either of us. I think I've made my points clear, and you can agree or not. But this discussion is over.

A:) said...

The only problem I have with this is what was quoted in the second paragraph -- calling mental illnesses brain disorders may cause some people to believe that originals are purely biological -- such as diabetes is a failure to make insulin.

Processes like thought, cognition, personal experience and environment etc -- do come into play to manifest various mental disorders and I don't think we can ignore this and attempt to reduce mental illness to a "brain disorder." Every action/emotion/thought has a biological correlate and we can't ignore this.

Sometimes I think those who promote the biological school of thuoght tend to rely to heavily on "mental illness is an imbalance/malfunction in the brain," etc at the cost of IGNORING possible environmental effects.

I am taking a neuroscience course now and one of the first things we learned was that even in ACCEPTED biological brain injuries like aphasia. there are biological and environmental components that are not additive but INTEGRATE to form the illness. . .

There are two polarized schools of thought at the moment. This can be seen with other theories as well in psychology -- usually neither AND both are right.

A:) said...

Also Carrie, do you have the research paper that sites the 80% risk factor as genetic?

I have heard 40-60% -- similar to schizophrenia

Unknown said...

Wonderful post. You've summed up the issues very well and thoughtfully.

Jing, well, gosh. I'm stunned by your bitterness and very personal attack on Carrie. Nothing Carrie said could possibly merit such unkindness so I'll just assume it isn't about her at all.

Carrie Arnold said...


That stat was from a presentation by Walter Kaye. If I had more time, I would try and dig up the reference, but unfortunately right now, I'm swamped. I'll definitely let you know if I run across it.

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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nour·ish: (v); to sustain with food or nutriment; supply with what is necessary for life, health, and growth; to cherish, foster, keep alive; to strengthen, build up, or promote


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