The Semiotic Model of Psychiatry

Switzerland, along with Austria, happens to be an early fertile spot for the fledgeling discipline of psychoanalysis and eventually psychiatry. As it happens, this connection played a part in the time I spent in Switzerland in May 2016 because of the unlikely connections I have to the weird intellectual world of Carl Jung and analysis.

In Switzerland I stayed with family who are tied into the world of Jungian analysis. My expenses there were somewhat underwritten because Switzerland happens to be a hub that some of my family has to frequent for academic work. There were Swiss francs lying around, rather uselessly, in America in my house. However, this connection to these areas of psychiatry and some things I was thinking about in Switzerland go somewhat deeper on a personal level.

I have my own intellectual cultivation in the other related areas of philosophy and cultural studies, I have my experiences with some segments of the world of treating mental illness, and I at least have a Wikipedia knowledge of some disorders and treatments. All this came together in the first half of last year for me and probably most fully took hold in Switzerland, even though I'd bumped into all the pieces before hand. A model of psychiatry I'd like to put forward, albeit loosely, today is a synthesis of these backgrounds. This is not really a peer reviewed, evidence based look at the issue, but I think it is well thought out and illuminating.

There can be a linguistic understanding of many mental illnesses that is variously ignored by or over attended to by the split world of treatments in mental health. In my experience there is a strong distinction to the point, almost, of disconnect between psychoanalysts and psychiatrists--the biology and the life of psychology.

That situation may be changing, perhaps starting with the rapidly developing views on addiction, but I think that there is reason to believe that a) the conditions of mental health from depression to schizophrenia can be linguistically construed; b) the existing medical treatments of these illnesses can be linguistically understood; c) there should be greater compatibility between the worlds of analysis and treatment along these lines.

I'd like to begin with a little bit of nomenclature that may not be consistent with the general definitions in the field. First and foremost I think that there is a distinction between what I will call neurosis and psychoses. For me neuroses are, frankly, the easier items to understand and prescribe around for reasons I'll elucidate further. Neuroses are the likes of anxiety, depression, and OCD, all really unpleasant things to deal with but for which there is growing, broad understanding. Psychoses, on the other hand, are the greater vagaries of psychology like personality disorders--paranoid, narcissistic, borderline--as well as the really difficult to treat and still poorly understood disorders like bi-polar and schizophrenia.

What is the difference between all these things? Well to begin with, it's useful to think about the brain as a device which makes decisions based on inputs. The brain takes in states of affairs, everything from a basket of dirty laundry to complex social interactions in groups, and has to put out decisions about those items. Neurosis and psychosis both arise, in a sense, from errant decisions about these inputs. The qualities in these errant outputs characterizes the disorder, neurosis or psychosis, at hand. Medication seek to tame these errant outputs. Finally, these issues can be understood as pieces of language occurring among neurons.

When a piece of information comes in, the brain has to make a decision about it. "What do I do about the dirty laundry?" "How do I feel about getting out of bed?" "What do I say to this person?" are the kinds of questions the brain makes decisions on all the time. Neuroses and psychoses mishandle the answers to these kinds of questions very differently and with different outcomes and this is underscored by the varying understanding and differing treatments that go along with neuroses and psychoses.

In general, especially in my experience with anxiety and depression, is that the decision reached is something I call vacuous. That is the answer to a question like "what do I do about the dirty laundry," isn't really an answer at all. It's essentially a dead end. In these cases depressives or anxious individuals might have a tendency to answer with a statement like I don't know what to do about the laundry. This is a vacuous answer, it doesn't provide any sort of guidance on what to do in a situation. Depressive and anxious individuals frequently have radically different views on what to do in these situations, but what characterizes these both as neuroses is that the underlying errant response to the syntactic formation of processing experiences is the same--they don't know what to do. The result is frequently either apathy or nervous energy in these cases but is also often paralyzing as the individual tries to correctly ascertain a solution to a problem.

On the other hand, there are these psychoses which seem to be reason giving in their errant, sometimes incomprehensible answers to inputs. Essentially, psychoses provide very emphatic answers to inputs which characterize the psychosis. For these individuals, mundanities are frequently of little consequence because the laundry is often the least of their concerns. Their answers about how they feel about dirty laundry or what to do about, though, is perhaps tellingly incomprehensible. I am doing/will do/can do the laundry is how a narcissist deals with these problems; There is/is not anything wrong with this dirty laundry is a paranoid answer. But take these answers to higher stakes situations and you quickly begin to run into the psychotic at the heart of psychosis--lacking real empathy and a tendency toward conspiracy. This action is malevolent towards me is a typical assessment by the paranoid.

A quick test to draw out the difference between these disorders of understanding is this, can the individual explain their actions? Depressives or anxious individuals frequently can not do this, "I don't know why, I just couldn't get out of bed today," or more generalized "what I have to do to complete this task (whatever it may be) is impossibly complex," people with these disorders would say. Individuals with psychoses frequently have ample explanation for their actions, they will point out the data that underlies what might be faulty reasoning. This is even true of individuals with depression and individuals experiencing bi-polar depressive episodes; depressives struggle to explain the cause of their depression, bi-polars point to reasons in the world for their depressive tendencies. (I'd also note that there is some debate if there aren't personality based depressives, or if depression can be a personality disorder, likely it's both, it's never a choice for the person though.)

This poses a problem from the point of view of treatments, but the distinction is present in medication for these kinds of disorders. The medications for depressives and the medications for bi-polars in depressive episodes differ greatly, an I think we can look at this as the medications have to accomplish different goals. This is why we have classes of medication which are SSRIs and SNRIs, versus anti-psychotics, versus other. And all of these things are out there at the edge of medical understanding, but here's my belief on the matter.

It's a lot easier to fill in the blank of a vacuous answer than it is to overrule a reason giving belief. Doctors really don't understand even what they're doing prescribing anti-psychotics and the side effects are horrifically varied. By comparison the SSRIs that make up the bulk of mental illness prescriptions are well understood, although not by much.

SSRIs work by leaving more serotonin in various synaptic clefts to be taken up. This neurological process essentially gives a person a boost as far a their mood is concerned. Zoloft, a popular SSRI which I've been on, really takes away the power your brain has to modulate the levels of he enthusiastic neurotransmitter serotonin and pegs it at the level of the prescription. This can be great when your mood tends toward apathy or towards tumult, but it also described by many as a feeling of flatlining emotionally.

But in a deep sense what Zoloft and drugs like it do is fill in an answer to the processing errors of the brain. Taking I don't know what I think about doing the laundry to I feel indifferent towards doing the laundry is a major help when the former is a description of the problem of doing the laundry. For psychoses, drugs must be reasoning with the the thinking in the semiology of neurotransmitters, adding negatives or denying access to certain areas of thought, and that inherently seems harder than covering up the issue regardless of the flatline problem.

But the big picture issue here is that this kind of thinking is what goes on in analysis. "Why did you think or feel that," could be the most generic statement for a therapist to make. Any good analyst or therapist will add meaning to those kinds of answers. Hopefully constructively. That's good for the person.

However, medication is often undertaking the same difficult procedures in neurological semiosis, but it can be prescribed by someone who isn't always attentive to what the patient is saying. Instead psychiatrists and doctors are looking for results. These results are really just reported by pretty simple thumbs-up/thumbs-down signaling rather than trying to parse what kind of answer the individual is getting from the medication in their situation.

So there it is. We need to be more attentive to the languages of our mental health. This is true for prescribers. But we also need to understand that the linguistic artifacts we parse on the therapists couch are the kinds of thing which are also taking place at a neurological level. In short, it's complicated, but I think there's an underlying framework for understanding the problems here.