Out of the Shadows
A leading psychiatrist contends that many of the problems we've always blamed on character flaws may be due to mild versions of full-blown mental disorders.
By John Ratey and Catherine Johnson published May 1, 1997 - last reviewed on June 9, 2016
Although the face Sandra presents to others is that of a relaxed and loyal friend, internally she is never at ease--she is driven to clean the house obsessively or diet obsessively, or, most recently, to shop obsessively, having run up a a debt of $15,000 within a few years' time. We might guess that Sandra comes from a dysfunctional family. Perhaps her parents were too demanding? or drank too much, or inflicted upon her their bad habits and character flaws. But neither we nor Sandra might suspect that there might be something biological going on.
Or take the case of Lou, a man who continually scans his body for signs of trouble, despite being in excellent condition for a man of 50. Lou not only worries obsessively about minor physical ailments, but compulsively questions his physician -wife about whether any of these troubles might be cancer. How do we explain Lou's behavior? Perhaps we see it as "normal craziness" similar to the obsessive neatness of the main character Jerry on the television show Seinfeld. Maybe we also view Lou as the victim of a bad childhood. What we don't think is that Lou, like Sandra, might be at the mercy of his own flawed brain chemistry.
But neuropsychiatry is now discovering that a great deal of "normal craziness" in fact is heavily influenced by the genetics, structure, and neurochemistry of the brain. Every troublesome personality likely has its roots in an unsuspected brain difference: the loner, the gifted person who cannot seem to live up to his or her potential, the needy neighbor you can't get off the telephone, the confirmed bachelor, the man who cannot talk about his feelings, or even the husband who throws tantrums like a four year old. Neurologists and biopsychiatrists are now finding that the normal problems of normal people are gray and silver shadow versions of full-color mental illnesses. They're the same thing in outline, but indistinct in detail, and not easy to recognize for what they are. Just as shadows cast a pall across a day that might otherwise be sunny and clear, these "shadow syndromes" cast a shadow over the realms of work and love.
Life changes when we begin to realize that people can have subtle, hidden, or partial mental disorders. The impulse to blame people or their parents for their problems loses its power. The profound and corrosive sense of shame we feel over our own behavior begins to lift when we understand that it can be created by subtle differences in the brain. And the notion of the shadow syndrome helps us to see that talk therapy needs to address our biological selves as well as our psychological selves. Sandra, for example, sought out therapists and doctors to help her change her behaviors, but they focused on the fact that she was adopted--a fact that she had thought little about. However her childhood may be affecting her, Sandra faces challenges shaped by the facts of her biology as well, and she needs the help of her therapists in doing so.
This is not to dismiss our environments as a major source of who and what we are. A child with an innately anxious temperament who is born to an innately anxious mother may grow up to be a different person from the child with the anxious temperament whose mother does not share his difficulty. But the "new" biology can help us understand how environment and biology work together to create the person--an understanding that we can use to make the changes we wish and hope to make.
In order to understand "normal craziness," we can learn from "craziness" that is not so normal, such as schizophrenia or severe manic depression. Psychiatrists diagnose their patients with these and other disorders according to syndromes described in DSM-IV, the Diagnostic and Statistical Manual, Fourth Edition. A syndrome is a set of behaviors that consistently appear together, and which the patient, the doctor, or the patient's friends and family can observed and describe. However, real people often come into the doctor's office exhibiting only one or two symptoms of a particular syndrome, or may fit every aspect of a syndrome down to the smallest detail and yet be so mildly affected that even a good therapist might miss the diagnosis. In fact, most everyday people seem to have minor bits of this syndrome, small pieces of that.
Lou's hypochondriacal behavior can be seen as a mild version of obsessive-compulsive disorder (OCD), and Sandra has shown "streaks" of the syndromes on the anxiety spectrum. Other common shadow syndromes are mild but hidden depression; hypomania, a mildly manic state where a person possesses extraordinary energy and productivity and lacks ordinary self-doubt; mild rage problems, such as that of the tantruming husband; mild attention deficit disorder (ADD), which does not unravel a life but may leave it disorganized; and autism-like social deficits that make a person incapable of relating well to others.
One of the most confusing issues is how many of the shadow syndromes normal people may fit. Sometimes depressed, sometimes impulsive, sometimes manic, sometimes obsessed: we may find aspects of ourselves, our families, and our friends in all of these categories. But there is one characteristic every shadow syndrome has in common: mental white noise. When we are mildly depressed, or mildly hyperactive, or mildly anything else, our brains cease to function as the quiet, reflective center of an ordered world. We become noisy on the inside.
What stress is to the body, noise is to the brain: the general response to the demands made upon it by difficult life circumstances or by flawed biology. The noisy brain cannot separate out stimuli or thoughts, either incoming or outgoing. For example, a person with mild ADD cannot filter stimuli from the environment; he or she will see everything out there, all at once.
A noisy brain invariably affects a person's capacity to deal with other people. Social skills occupy the very topmost level of the brain. Noise affects this top level, or cortex, causing the person afflicted to fall back to a more primitive, "lower" level of brain functioning that corresponds to the social strategies of the adolescent or child--or lower still, to the level of the "reptilian brain," where we respond reflexively instead of thoughtfully.
BRAIN BASED BEHAVIOR
How do we know that this mental white noise is biologically based? In the case of obsessive compulsive disorder, researchers have identified three specific brain structures that become locked together in a pattern and cause the behavior. Any damage to the primary brain structure, the caudate nucleus, whether from "bad genes," head injury, or even from the body's own immune system, can result in obsessive-compulsive disorder. In fact, OCD can develop in children as a result of a strep throat infection. The same antibody that attacks strep can also attack the caudate nucleus, causing a child to develop obsessive fears of contamination and to begin compulsively hand-washing. Treatment with blood plasma and antibiotics makes these symptoms decline noticeably.
But unlike obsessive-compulsive disorder, other shadow syndromes such as adult tantruming do not have their roots in a simple biological problem. In fact, many readers will be skeptical as to whether adult tantruming has a biological explanation at all. And yet antidepressant medications have been shown to stop anger attacks altogether in 71 percent of a group of depressed patients, and reduce their incidence in the rest. This fact alone implies that for these patients, tantrums had a significant brain-based component.
It is also likely that temper tantrums in people who are not depressed are just as biologically based as anger attacks in depressed people. The experience of Gary, a man who averaged forty tantrums a month, provides evidence for this conclusion. By the time he went to see a psychiatrist, Gary had exhausted almost every available avenue to master his temper, except for medication. He had been a sober member of Alcoholics Anonymous for 10 years; he regularly attended a men's group to discuss feelings and relationships; he had been a runner for years; he had religiously practiced breathing, meditation, and relaxation exercises to calm himself. And none of it had worked. His second marriage was on the brink of collapse and his small daughter was terrified.
Gary went to see a psychiatrist because he had read about attention deficit disorder, and recognized symptoms in himself. The psychiatrist confirmed Gary's self-diagnosis, and prescribed a low dosage of the medication desipramine as treatment. Later, Gary self-consciously revealed a side benefit from the medication: He had stopped having tantrums at home.
The fact that desipramine worked so well for Gary indicates that his tantrums very likely were the result of brain noise produced by random firings of the brain stem. An excess of mental noise from this lower region, which connects the brain with the spinal cord, can overwhelm the higher brain centers, the "seat of reason" found in the frontal lobes of the cortex, and allow the lower emotional brain to take over. In other words, emotion "hijacks" reason. Desipramine may act to reduce random, noisy brain-stem firings. By quieting these posterior areas, desipramine may then permit the frontal lobes to step in and stave off a rage attack.
A WHOLESOME SOLUTION
Gary's experience shows how a person can go about changing the way his or her brain works. First, the person must try to develop insight--to see himself as his loved ones see him. The person also needs to consult a doctor, and listen to what that doctor tells him or her about brain chemistry. Then, working with the doctor and loved ones, the person needs to create tools to short-circuit his or her biologically-based response to daily life. (Some examples are described below.) Finally, if these measures are not sufficient, he or she may have to take medication to restore brain functioning.
While relaxation exercises had not worked for Gary's rage attacks, insight and behavioral techniques alone have helped many people with shadow syndromes change. In a revolutionary ULCA study obsessive compulsive patients--those suffering from symptoms more severe than Sandra's or Lou's--were required to tell themselves that the obsession they were experiencing was not real. Then they resisted performing the compulsion and instead forced themselves to do something wholesome and enjoyable--such as a hobby, volunteer work, or a good deed for a friend or a loved one--for at least 15 minutes. Twelve out of 18 patients in the study experienced striking reductions in their obsessive-compulsive symptoms. And, remarkably, the changes were reflected in before-and-after brain scans. In the "after" scans, several brain areas had begun to operate as they do in the normal brain. The UCLA researchers demonstrated the power of the mind to bend a malfunctioning brain to its will.
BOOSTING BRAIN PERFORMANCE
When it comes to making small changes in our lives and brains, the motto to embrace is: Everything matters. Exercise, food, sleep, the work we do, whom we marry--all of it affects our brains.
Perhaps the most important modest change any of us can make is to establish an exercise program, and stick to it. A growing body of evidence links aerobic exercise to sharpened memory, faster response times, elevated mood, and increased self-esteem. Most of these studies have been conducted on the elderly, but the results are so encouraging that many clinicians are convinced that even young children may benefit from a program of daily exercise.
Martial arts, forms of exercise that train the mind as well as the body, have helped a number of patients with shadow syndromes to make tremendous progress in their lives. Like meditation, which is also an excellent tool for soothing the noisy brain, martial arts train the body and brain to a achieve a state of relaxed readiness, which allows the trainee to react to any challenge without having to anticipate it.
We can also influence brain chemistry for the better through food, light, and sleep. Clear data indicate that light is good unless you are manic, and sleep is good unless you are depressed (when it may be bad). Food is a more complicated issue. For example, pure carbohydrates unaccompanied by fat may soothe anxiety, but decrease alertness at the same time. Whatever enters our bloodstream, from wheat germ to pork crackling, may affect the brain in a matter of seconds.
Beyond the common-sense tactic of striving to develop good habits in exercise and diet, we should hold ourselves open to the mysteries of the body and its brain. Solutions can come from places we would never look, and if we notice a positive effect in our own life, whether from food or exercise or sleep or light or negative ions or simply the scent of autumn in the air, we should take it seriously.
Apart from these changes, the single most critical improvement anyone can make in brain function, and in character, is to find a mission in life. It is well known that idleness increases psychiatric and physical symptoms of all kinds. And almost any form of work, even work we do not particularly enjoy, can quiet the noisy brain. Work stimulates the cheer-seeking left side of the brain, taking us out of the stewing morass that is the right. An impassioned commitment to an activity pushes brain function in the direction of health, sanity, and well-being.
THE WINGS OF CHANGE
Perhaps the most useful theorem for anyone trying to change his brain is meteorologist Edward Lorenz's now famous "butterfly effect": a butterfly flapping its wings in Tokyo, he imagined, could set off a cascading chain of events that ended up as a hurricane over Texas. This theorem applies to mental fitness as well. The brain's interconnectivity tells us that small problems may cascade into large ones, so it can be important not to let even minor mental issues slide.
However, the good news is that complex systems such as the brain do not list in just one direction: Life is not inevitably a downhill proposition. A change as small as a new exercise program or a satisfying hobby might make all the difference in the world.
For most of us, the notion that a complex system may tip up as well as down is counterintuitive. As a culture, we have taken the second law of thermodynamics to heart: entropy rules. But we do possess some intuitive understanding of an anti-entropy force at work in life and love, when we speak of "things falling into place," or of being "on a roll," or when athletes hit "a winning streak." All of these experiences are, in a sense what we are hoping for when we think of changing our lives. We are hoping to reach that magic moment when life and love "self organize" into something splendid.
With greater knowledge of the brain's biology, people who struggle with shadow syndromes can move closer to that goal. We hope that the shame of having to live life as a flawed human being will eventually fade, and the potential to free the self from the bonds of biology will grow strong. We hope that it will help people to begin the journey out from the shadows and into the clear light of day.
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From the book Shadow Syndromes by John Ratey, M.D., and Catherine Johnson, Ph.D. Copyright copyright 1997 by John Ratey, M.D., and Catherine Johnson, Ph.D. Reprinted by permission of Pantheon Books, a division of Random House, Inc.