A Paradigm Shift

A Paradigm Shift

Our professional field is moving in a positive direction of a paradigm shift in helping people recover from their trauma wounds. For over 120 years psychiatrists and psychologists have been working with a model based upon identifying and treating psychopathology. We have focused on trying to understand human emotional and mental problems by identifying commonalities, classifying them, diagnosing them, and then designing treatment methods for the various types of psychopathologies. This model has served us well and has been and will continue to be useful in working with patients, particularly those with brain disorders or serious mental illness. Today however, with more knowledge of human development, attachment, the autonomic nervous system, mindfulness, affect regulation, and the brain-body connection we can expand how we look at our patients. We are now able in many cases to move trans-diagnostically and see our patients through the lens of a more holistic model, particularly through neuro-regulation. The neuro-regulation model (which is covered in detail in the complex concepts section) allows us to look at our patients more as individuals and encourages to focus more on strengths, resources, and resiliency.

Regulation theory is a more concise and consistent explanatory model of human behavior. The focus moves from “What is wrong with the patient?” to “How can we support this person to have better nervous system regulation, improved interpersonal relationships, and build resiliency?” Under regulation theory our mental and emotional problems come down to difficulty managing nervous system arousal and difficulty navigating interpersonal relationships. Both are linked; that is the better our regulation, the better our relationships, The worse our regulation is, the worse our interpersonal relationships are. For instance, for non-psychotic patients the group with the most dysregulation is those we refer to as “borderline”. The non-psychotic group with very troublesome relationships is the group we refer to as “borderline”.

But what does this mean for those with significant psychiatric diagnoses such as schizophrenia, bipolar disorder, OCD, severe major depression, etc. and what about those with brain disorders such as developmental delay, ADHD, and autism? If we put aside temporarily, for now, the underlying brain abnormalities associated with these disorders, what are we trying to help these people with? Better nervous system regulation and better interpersonal relationships. We need to see these patients primarily as human beings who have many of the same problems we all do. By focusing on what is wrong with them, the psychopathology, our interventions have focused on treatment with medications. So much so it is difficult in some places now to find a psychiatrist who does more than “medication management”. Also, psychosocial interventions for those who have serious mental illnesses tended to be far short of what these people need.

If we shift to a neuroregulatory model, I think we will provide better treatment for more severe psychiatric problems. Let us look at the mental illnesses in another way. Our categorical diagnoses, such as schizophrenia, are too simple. From a neuroregulatory standpoint there is no such thing as schizophrenia. By this I do not mean this serious mental illness does not exist. What I mean is that the symptoms we see are a final common pathway for a variety of brain disorders that show up as the phenotype we call schizophrenia. It is the same for the bipolar disorders. We even know this as we have a challenging time discerning bipolar I vs bipolar II vs cyclothymia vs “borderline”. From a neuroregulatory standpoint that difficulty is because there is no such thing as bipolar disorder. Again, by this I do not mean that these illnesses do not exist. The phenotype we see are final common pathways for a variety of brain difficulties.

The point am making is that schizophrenia and bipolar disorders are much more complicated than a single category. For instance, in cardiology heart failure is the phenotype we see that is a final common pathway of a variety of heart and lung problems. We need to see the serious mental illnesses in the same light. I believe then we will be able to focus more on each individual just as a cardiologist looks at each heart failure patient needing different interventions. Another example from the psychiatric field is depression. Depression is a final common pathway of many problems such as genetic predisposition, childhood trauma, alcohol and drug abuse, chronic pain, grief and loss, hormonal problems, medical problems such as diabetes, cardiac disease, and autoimmune disorders as well as nutrition, exercise etc. There is no such thing as depression as a single illness.

My thought is if all our psychiatric treatments continue to be based upon these final common pathway diagnoses, our interventions will continue to be only moderately effective. The sad fact is that from the first antidepressant medications and the first antipsychotic medications from the late 1950’s and early 1960’s we do not have significantly better outcomes now as we did back then. Even our most effective treatment for severe depression is electroconvulsive therapy which goes back to the 1930’s. Now we have developed treatments with far fewer side effects, fewer health risks, and better safety profiles. There is also more access to these treatments than in the past. However, our outcomes are not much better than years ago.

Let’s look at some of the limitations in our current ways of treating the final common pathway diagnoses of depression, bipolar disorders, and schizophrenia. Now when we diagnose depression, we tend to prescribe antidepressants or cognitive-behavioral therapy or both. If we use the neuroregulatory final common pathway model we will also address the alcohol or drug problems we often miss, as well as the childhood trauma, the chronic pain, the grief and loss, the contributing medical illnesses, possible hormonal difficulties, and diet and exercise. When we look at it in this light, we can see that the psychiatric 15 minute “med check” is not only ludicrous but a travesty as well.

In the bipolar disorders we often don’t address many of the same factors as above. But by not looking at each individual’s relapse issues we don’t look beyond medication. And we don’t see that many relapses occur because we are not seeing that in these disorders, nervous system dysregulation is noticeable and precedes full blown relapses.

In schizophrenia nervous system dysregulation is probably the major factor involved in relapses other than medication compliance and drug or alcohol issue. If we don’t address adequately barriers to housing, social support, cannabis abuse, poverty, reasons for medication non-compliance as well as the ongoing traumas these individuals experience it is very difficult if not impossible for them to be able to have a well- regulated nervous system. No wonder our outcomes are so poor. We have emptied the state hospitals with symptom improvement but have ignored all these other needs so have simply put them on the streets instead.

So, if our assessments look not just at symptoms but the nervous system regulation issues and the corresponding interpersonal problems and support issues, we are much more likely to address the many contributors to poor outcomes and also more likely to see our psychiatric patients as human beings instead. This is what I mean by a needed paradigm shift.