I am fortunate to have a challenging job that requires flexibility and creativity, but it’s often difficult and sometimes downright exhausting. One time I complained about this effortful experience to our former chief of staff, Richard Munich, and he responded, “That’s why they call it work!” I find Dick’s matter-of-fact attitude toward the difficulty of work to be consoling, and I repeat his words to myself when I struggle to marshal the required effort.

Living requires brain power, and challenging work pushes brain power to the limit. Of all our body organs, the brain uses the most energy. Compared to other animals, the human prefrontal cortex occupies a disproportionate amount of brain territory. This brain region plays a key role in challenging work, and its activity consumes a lot of energy.

Demanding work

I was dumbstruck when I came across a list of specific challenges that tax our prefrontal cortex; I thought immediately, “That’s work!” Here’s the list that grabbed my attention, compiled by Paul Burgess and colleagues at University College London:

1. A number of discrete and different tasks have to be completed.
2. Performance on these tasks needs to be dovetailed in order to be time-effective.
3. Due to either cognitive or physical constraints, only one task can be performed at any one time.
4. The times for return to task are not signaled directly by the situation.
5. There is no moment-by-moment performance feedback … failures are not signaled at the time they occur.
6. Unforeseen interruptions, sometimes of high priority, will occasionally occur, and things will not always go as planned.
7. Tasks usually differ in terms of priority, difficulty and the length of time they will occupy.
8. People decide for themselves what constitutes adequate performance.

Broadly speaking, these challenges call for multitasking. These prefrontal capacities are called “executive” functions, and the list I just quoted would be as familiar to “executives” at work as it was to me. We are all executives. In our increasingly multitasking world, this list is typical of the demands of many persons’ daily lives, going far beyond professional work. Review the list while holding in mind the demands of raising children and running a household.

The prefrontal cortex and mentalizing

Consider also challenging interpersonal situations with this list in mind. A common example is working on a complicated project while trying to forge collaboration among several group members — or family members. Yet much of the list also pertains to difficult negotiations in a relationship, for example, parents coordinating the demands of work, childcare and household responsibilities. As you may have noticed, relating to people can be hard work. Mentalizing — attending to mental states in others and yourself — is part of this interpersonal work. Consistent with the complexity of interpersonal problem solving — and managing our own desires, thoughts, and feelings — the prefrontal cortex plays a key role in mentalizing.

Unfortunately, common psychiatric disorders impair the functioning of the prefrontal cortex, thereby compromising the capacity to engage in complex problem solving — intellectual and interpersonal — that our contemporary multitasking world demands. Thus it is not surprising that psychiatric disorders can be associated with significant disability in occupational and social functioning.

Some appreciation of their neurobiological basis helps us take psychiatric disorders seriously as physical illnesses, which can help combat stigma. Fortunately, treatment of psychiatric disorders — not only with medication but also psychotherapy — normalizes brain function, enabling patients to resume the challenging work of everyday living.

Editor’s note: If you enjoyed Dr. Allen’s post, please check out some of his other recent posts:

• POT: What’s new in plain old therapy?
• Was the Sandy Hook mass shooting “evil?”
• Can’t AND won’t

Reference                 

Burgess, P.W., Gonen-Yaacovi, G., & Volle, E. (2012). Rostral prefrontal cortex: What neuroimaging can learn from human neuropsychology. In B. Levine & F.I.M. Craik (Eds.), Mind and the frontal lobes: Cognition, behavior, and brain imaging, pp. 47-92. New York: Oxford University Press. (The list of challenges is quoted from page 81.)

I’ve adopted the term biomania to refer to what I see as excessive enthusiasm for an exclusively biological approach to understanding and treating psychiatric disorders. As a psychologist who practices psychotherapy, I share enthusiasm for neurobiological understanding, and I am grateful for effective biological treatments that help patients make good use of psychotherapy. I am hopeful that neurobiological research will contribute to the development of increasingly effective uses of psychiatric medications as well as novel biological treatments. Moreover, I believe we can help ameliorate stigma associated with mental illness through recognition that, like other medical conditions, psychiatric disorders have a biological basis. My objection relates to an exclusive emphasis on biology that leaves the person out of the picture.

Notoriously, decades ago psychiatrist Thomas Szasz went too far in the opposite direction from biomania, as captured in the title of his 1974 book The Myth of Mental Illness, in which he proclaimed that psychiatry deals with problems in living, not illnesses. As decades of neurobiological research amply demonstrates, psychiatric disorders are physical illnesses: many have a genetic basis, and neuroimaging research shows alterations in brain functioning associated with these illnesses.

Problems in living

I think Szasz was obviously wrong in failing to acknowledge psychiatric illness, but he was right in drawing attention to problems in living. Let me use major depression—a well defined, common, and serious psychiatric disorder—to illustrate my point. Major depression is a state of high physiological stress, and functional neuroimaging studies typically show high emotional arousal in conjunction with impairment in the prefrontal cortex, an “executive” area of the brain that is active in planning and organizing activity, thus pivotal in complex problem solving.

Seriously depressed persons have no doubt that they are ill, and they are not surprised to learn that their brain is not functioning optimally. In his brilliant memoir Darkness Visible, author William Styron noted how depression resulted from an “aberrant biochemical process.” Here is how he experienced the altered biochemistry:

“With all of this upheaval in the brain tissues, the alternate drenching and deprivation, it is no wonder that the mind begins to feel aggrieved, stricken, and the muddied thought processes register the distress of an organ in convulsion.”

He concluded, “It is a storm indeed, but a storm of murk.”

Stress pileup

What is the basis of these adverse brain changes? We know that episodes of depression stem from a combination of genetic vulnerability and psychological stress. I have used the idea of “stress pileup” to characterize the psychological stress that builds up over a person’s lifetime. Not uncommonly, an interaction of genetic risk with childhood adversity such as loss and trauma sets the stage for adulthood stress to trigger a depressive episode. Often enough, stressful events that can trigger episodes are completely beyond the individual’s control: death of a loved one, natural disasters, general medical illnesses, accidents. Yet much of the time, the stress that contributes to depression is partly self-generated: overwork, perfectionism and the self-criticism that goes with it and—most prominently—interpersonal conflicts. These latter sources of stress can be viewed as problems in living; they are psychological and interpersonal.

I remember one day in a patient education group explaining the stress pileup view of depression and going through a cascade of psychological and interpersonal stressors that can ensue over time. A patient piped up and said, “But my doctor says I have a chemical-imbalance depression.” I replied that all depression is biochemical. The question is: What causes these biochemical changes (and alterations in patterns of brain activity)? An important part of the answer is psychological stress. The stress pileup view and chemical imbalance view are complementary, not mutually exclusive.

In need of something more

The field of mental health needs neuroscientists who are biomanics, that is, passionately excited about researching the biology of psychiatric disorders. But there is a danger of clinicians and patients becoming biomanics, as biomania can be associated with an exclusive focus on biological treatments. Many patients become demoralized after trying multiple medications and combinations with limited benefit; they need something more. Szasz was half-right: to the extent that stress plays a role in the development, perpetuation and recurrence of psychiatric disorders, we must pay attention to problems in living—that is, problems in thinking, feeling, behaving and relating. No doubt, effective psychiatric medication can help enormously with problems in living that stem from psychiatric disorders. But we also know that many forms of psychotherapy are highly effective in treating psychiatric disorders insofar as they directly address problems in living and promote new learning. Hence psychotherapy and medication can complement each other, and research suggests that combining the two is most effective for severe depression.

Psychology and biology are thoroughly intertwined. We know that the quality of early relationships influences brain development; moreover, the quality of the patient-therapist relationship plays a central role in the effectiveness of psychotherapy. Furthermore, psychotherapy, like medication, has been shown to affect patterns of brain functioning. Yet we still have much to learn about all these matters, and we can count on biomanics along with psychotherapy researchers to bring continuing progress in our efforts to treat more than the illness, namely, the person who is ill.