Oliver James was smaller than I thought he would be. Thin and balding with straggly dark hair and beady eyes behind large dark framed glasses, he was dressed in grey sort of knitted jerkin and narrow Crimson corduroy trousers and seemed to have some instability in his gait. Oliver James is a psychotherapist, writer and broadcaster, who likes to provoke. A collection of polemics, his books: Affluenza, They Fxxx You Up, Contented Dementia, Britain on the Couch, draw attention to the failings of western society with regard to the understanding, causation and treatment of mental illness.
He was the guest of honour at the Sheffield University Counselling Service last Thursday. Billed improbably as talking about the human genome, he was there to discuss with a panel of experts his latest paper, Not in Your Genes, which attacks the idea that genes have anything to do with the transmission of mental illness from parent to child. His argument was straightforward, almost self evident. It reminded me of Richard Dawkins treatise on ‘The God Delusion’.
Despite the unraveling of the human genome in time for a new millennium, James claimed that it was widely acknowledged that there was minimal evidence that genes were involved. Even the powerful Genome Wide Association studies, which examined the differences across the genome between those with specific mental illnesses and those without, concluded that genetics contributed more than three percent of the variance for schizophrenia, attention deficit disorder, autism, and as for as depression was concerned none at all. Debunking the seemingly powerful evidence of similar behavioural traits in identical twins compared with non-identical twins, James pointed out that non identical are more likely to have been treated differently, so environmental factors might have been more important. Even in the few instances when identical twins had been separated at birth, James asserted that the separation is not always complete; separated twins often know and may identify with their twin. In no circumstance, he continued, could you exclude the effect of early environment in explaining the traits in behaviour or mental illness that ran in families. Families lived in the same environment, experienced he same events, ate the same food and harboured the same micro-organisms in their colons. Was it at all surprising that they behaved or reacted to circumstances the same way?
The brain, which controls the way we are, grows as a result of our experience. ‘What happens’ makes connections between neurones, and the more those connections are used – the more we think about something or react a certain way, the more they become established until they can become us, the way we are. It’s like paths through the forest. What is personality but the way we respond to aspects of our environment. It seems self evident that we are likely to react in a certain way if that was cultivated in us by our parents. This is not genetic transmission, but memetic transmission by thought and idea, though James almost undermined his own argument by showing a home video of his son, dribbling a football. James was also an expert dribbler in his youth but his son had never seen his father play football. So was there something in the genes or was it the transmission of an idea, an aspiration? Children pattern their own personality on that of an admired parent. Did the fact that my father crashed his Hawker Hurricane in 1941 explain my desire to learn to fly with the RAF as someone my headmaster described as an ‘air minded youth’?
What Oliver James didn’t point out was that the notion that genes might be involved in mental illness is confounded by a dysjunction of paradigms. Genes encode for proteins, which serve as catalysts or building blocks for certain metabolic processes. Psychiatric Diseases as listed in the encyclopaedic DSM V are a set of pragmatic diagnoses, based not on any biological marker or pathological process but on a description of symptoms. There is nothing specific in any of them; they all overlap. Depression is an important component of schizophrenia, which might be considered at the far end of an autistic spectrum, which includes attention deficit disorder. The classification of psychiatric diseases is a collection of overlapping descriptions or traits; pragmatic solutions that help doctors much more than their patients. In fact, it could be argued that putting patients in labelled boxes has hindered the understanding and treatment of patients by obscuring the real entity. Broad categories of psychosis and neurosis may be useful but they describe traits which we are all subject to, but these can change according to how the social environment changes. We can all lose contact with reality when in the grip of love, religion or watching a film. Depression always has elements of unreal and magical thinking. Psychiatric drugs are either downers or uppers; they all do much the same thing.
Not only that, but the nature/nurture argument is a false dichotomy. The study of epigenetics has shown how the environment, the food we eat, our society, the things that happen to us can alter the expression of genes. One of the most influential studies claimed to show that certain variants in the promoter region of the serotonin transporter gene created vulnerability to depression when combined with childhood maltreatment, but most studies have failed to reproduce these results. Interestingly, this same gene has been implicated in IBS.
Until we can think about psychiatric illness as not so much as different entities defined by symptoms, but as different expressions of something much more inclusive, perhaps an overarching state of dysphoria, will we ever find definite markers and a specific causes? Oliver James claimed that most mental illness was the consequence of trauma and disturbances in attachment. Psychiatrist, Professor Tim Kendall asserted that poor parenting impairs children’s behavior and can make them ill and advocated that more money should be spent on training parents how to bring up their children, setting boundaries, engaging, but also allowing them the freedom to explore. So can a large component of mental illness be put down to the way parents rear their children? if so, what has society come to if we have to train parents how to bring up their children? And can you actually ‘teach’ parents or is it more a matter of creating the right social environment? Austerity creates debt and debit is a major component of mental illness and poor parenting. So, suggested Oliver James, why doesn’t the Government just increase the national average wage?
In a broad ranging discussion, the panel considered the idea that mental illness can recover spontaneously, given the right environment. Hunter gatherer communities probably did it better because the essential components of connection, engagement, recognition, acceptance and identity came naturally. These components may be absent when parents are always on Facebook and their children not subdued by television and ‘computer games’. But as Ina commented to me yesterday, I may not see my neighbours, but Facebook offers me friends all over the world.
Does this sound familiar? Although Oliver James was talking about psychiatric diseases and did not mention IBS, the features and symptoms of IBS certainly overlap with a range of psychological and other medically unexplained illnesses Moreover, there are no specific effective treatments, but they can all respond to antidepressants, psychotherapy and complementary therapies. Genetic studies of either the human genome or the colonic microbiome have so far not revealed anything useful for IBS. Nevertheless, there is a compelling evidence to indicate that a significant proportion of IBS may be the ‘visceral expressions of what has happened’ and that early life experience may condition the gut reaction. People with both psychological and medically unexplained disorders are either considerably distressed by their illness or not at all distressed (la belle indifference). But more of that later.