Measuring the mind.
Interview: Urs Hafner
The soul is less susceptible to medical examination than a conspicuous skin blemish or a broken leg. Annette Brühl believes blood tests and brain scans could unlock new possibilities for psychiatry.
UNI NOVA: Professor Brühl, you are a professor of affective disorders – emotional disturbances, you might say. Aren’t strong emotions always disturbing?
ANNETTE BRÜHL: No, I think that emotions are the spice of life. They’re important because they tell us what we like, and what we don’t. They help us to get to know ourselves better. That said, a dish can have too much chili or salt in it, and that just makes it unpalatable.
UNI NOVA: At what point do emotions become unpalatable?
BRÜHL: Let’s take an example: losing a loved one. If the bereaved person can’t get out of bed for a week, it’s acceptable, but if they get into a state of such despair that they stay in bed for a month, that’s a cause for concern and will have a negative effect on their life. Time is just one factor among many, however. There’s also the intensity of their grief, or the impact it can have on their own life and their surroundings. When a person is utterly unable to let go of a particular event and regain their balance, this might indicate depression or the need for help.
UNI NOVA: We also see this inability to let go in less tragic contexts, such as the end of the requirement to wear a mask outdoors earlier this summer. Many people were still walking around wearing masks. Are they on the brink of an emotional disorder?
BRÜHL: I wouldn’t say so. For one thing, in countries like Japan or South Korea, wearing a face mask in the event of an infectious disease was common practice before the pandemic, and, for another, doing so is unproblematic as long as the wearer is not bothering anyone or suffering themselves as a result. Things get a bit more complicated if the person develops an extreme obsession with washing and hygiene.
UNI NOVA: And what if they take pleasure in suffering?
BRÜHL: You’re referring to masochism? Well, if the person derives a positive overall balance from their life with the obsession, that’s all very well for them – but what about their surroundings? I had a client who demanded that her husband disinfect himself from head to toe and change his clothes every time he entered their home.
UNI NOVA: An amateur psychologist might say she was trying to get rid of her husband …
BRÜHL: No, she was simply terrified of Covid-19 infections, particularly for her child. She would spend hours washing her hands every day. The dog had to do its business on the balcony, and her child wasn’t allowed to leave the house. Her obsession was having a significant impact on those around her.
UNI NOVA: What did you do?
BRÜHL: Fortunately, her symptoms were still fresh, and had not yet become chronic. I gave the patient some clear information about the pandemic, a realistic assessment of the risk potential, and strict instructions to stop avoiding the source of her anxiety. This is the crucial point.
UNI NOVA: So you cured her?
BRÜHL: She started leaving the house with her child and her dog again. She realized that facing up to her fears wouldn’t end in disaster.
UNI NOVA: This patient behaved in an exemplary and rational manner. What do you do when patients won’t listen to you?
BRÜHL: In this case the cure wasn’t just a matter of rational behavior: I began by prescribing the woman a psychiatric drug, as the stress was stopping her from sleeping. This mood enhancer paved the way for successful psychotherapeutic treatment. But the same principle applies to more serious cases too: The patient has to ascertain which fears and behaviors are standing in their way, and find the motivation to lead a life that is compatible with their goals and values. If I had treated the woman at a later stage, perhaps her much-disinfected husband would already have left her, or her recluse child would have fallen behind at school, and she would be desperate. But the basic process would not have been any different.
UNI NOVA: We’re often told that the pandemic has led to a spike in mental illness. What is your take on that?
BRÜHL: Neither in Basel nor in Zurich, where I worked previously, has there been any evidence of a clear increase in diagnosed cases of mental illness so far. Grieving for someone who has died of Covid-19 is not a sign of illness in itself. It’s only if someone can’t find their way past the grief and is paralyzed by it that it becomes a mental health issue. That’s something that we can only ascertain after some time though, so we may well see a rise in patient numbers soon. And let’s not forget: While terrifying for many people, for others the coronavirus pandemic has actually had the effect of relieving tensions such as conflicts in the workplace. These two aspects might balance each other out.
UNI NOVA: But the Corona Stress Study reported an increase in depressive symptoms among the population. How do you explain this mismatch with your experience?
BRÜHL: Depressive symptoms are a long way from mental illness. If I missed going out with friends during lockdown, that might make me sad, but it doesn’t mean I’m depressed. Sadness is an appropriate reaction to the situation. If I’m able to find joy in other things, occupy myself with hobbies, and then perk up again once the restrictions are lifted and the risk subsides, then you could say I was under a certain amount of strain for a time – but I’m not depressed. Patients with depression are sad, joyless and apathetic in spite of a positive environment.
UNI NOVA: For years now, every new update of the DSM classification of mental disorders has included new illnesses. Are people getting crazier, or are we just being examined more closely?
BRÜHL: The latter! Right now, psychiatry is where internal medicine was maybe in the 1970s. We are getting more precise all the time. Psychiatry is a relatively young science – it has only been around for a little over a century. Around the year 1900, it only had three diagnoses to choose from: depression, mania and neurosis. Moreover, it was primarily a descriptive science, noting symptoms and progressions without any awareness of the causes. We’ve come a long way since then.
UNI NOVA: That sounds hopeful. Then again, history shows us that mental illnesses come and go. Hysteria is no longer a diagnosis, as recently as the 1980s homosexuality was considered a disorder, and today’s children suffer from dysphoria and gender identity disorder. Does each society create its own illnesses?
BRÜHL: More so than other fields of medicine, psychiatry is closely intertwined with social and moral issues. For a dermatologist, a skin blemish is just a skin blemish, but a person’s fears are much harder to quantify. This is precisely why biology is so important to us. It gives us access to a new dimension. I believe that we will soon be able to match up clearly defined groups of diseases with the appropriate medications, in the same way that oncologists administer treatments for breast cancer on the basis of genetic factors.
UNI NOVA: What do you mean by biology?
BRÜHL: Analysis of data pertaining to the patient’s brain and blood and other measurements. Taking biology into account makes our discipline more objective, as we’re adding another dimension to the patient’s subjectivity. But we’re still at the beginning. As we’re not yet able to work with precise laboratory results or brain scans like internal medicine does, for the most part we still have to rely on the testimony of the person being examined.
UNI NOVA: Time and again, psychiatry has looked for the causes of mental illness in the body. Around the middle of the 20th century, the dominant theory was hereditary biology, according to which feeblemindedness was passed from one generation to the next, but this idea was abandoned. Is psychiatry going round in circles?
BRÜHL: Genetic research has come a long way since then! We now know there is no single gene for depression or schizophrenia. Mental illnesses can be hereditary, but the process is much more complex than a single gene. There are no psychiatric illnesses caused by a single inherited gene. Rather, these illnesses are caused by the interplay of numerous minor genetic factors. Thanks to genetic analyses, we now know that bipolar disorders, which manifest in manic depression, are genetically closer to schizophrenia than they are to unipolar depression. This knowledge has allowed us to treat these illnesses more successfully. With even more data, we will be able to prescribe medications with even greater accuracy.
UNI NOVA: Do you also see any disadvantages in drug-based psychiatry, such as patients going through life subdued and bereft of emotions?
BRÜHL: If someone is going through life subdued, then they’re not getting the right treatment. Treatment always includes psychotherapeutic elements, too. The focus might lean more toward drugs or psychotherapy depending on the illness, but treatment is never solely drugbased. In general, it should allow the patient to feel both positive and negative emotions with the right level of intensity for them, minimize their suffering and let them lead a full life.
UNI NOVA: You deal with people who exist at the boundary between what is considered normal and what is not on a daily basis. Has this affected your outlook on life?
BRÜHL: You’d have to ask my friends. I’m not the brooding type who loses touch with reality, and I’m blessed with the ability to simply close the door behind me at the end of the day and leave my work at the office. Over the years I have become more understanding of the variety of different forms people’s lives can take. It never ceases to amaze me how people manage to live a good life in spite of their illness. But I hardly ever watch films that prominently feature psychiatric issues any more, such as «Black Swan» or «One Flew Over the Cuckoo’s Nest». Their portrayal of mental illness tends to be so skewed that I would just get upset and annoy whoever I was with.
UNI NOVA: These films express a certain discomfort in relation to psychiatry. Where might this come from?
BRÜHL: There is no question that psychiatry has been co-opted in the service of morally questionable decisions or used to exclude certain people in the past. Things are different now; my experience of psychiatry as a field is that it is considered and ethically aware. On top of this, the general public associates a certain degree of discomfort and stigma to mental illness, as it affects people in a very direct manner while being difficult to understand – unlike a broken leg or a tumor, which are plainly visible on an X-ray scan. Finally, the population at large knows much less about what actually goes on in psychiatry than in a field like surgery, for instance. Psychiatry needs greater visibility, and the public needs more realistic information.
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