WHY EVOLUTIONARY THEORY SHOULD GUIDE THE NEW PARADIGM SHIFT IN PSYCHIATRY

SACHIN SARIN MD

              Tinbergen (1963) famously described a framework for understanding behavior in which he emphasized that in order to understand behavior we must appreciate not only its proximate but also its ultimate or evolutionary causes. While evolutionary theory has long been touted as critically important towards our understanding of human pathology (Williams & Nesse 1991; Nesse & Williams 1996; Nesse et al, 2010) the field of psychiatry has largely ignored evolutionary theory (Brüne 2012). 

Instead, the predominant nosology of psychiatric diagnosis, the DSM 5, relies on a speculative constellation of symptoms, called disorders, which are deemed present or absent in a dynamic but otherwise dichotomous manner. This translation, from dimensional to categorical model, necessarily leads to a loss of information, in this instance limiting a more in depth understanding of the ailments affecting psychiatric patients. Further, the current model of psychiatric diagnosis has impeded advances of novel therapeutic and research models in psychiatric illnesses (Holtzheimer and Mayberg, 2011). Any further improvement in the efficacy of pharmacotherapy for psychiatric disorders is inherently limited because each disorder represents a heterogeneous group of syndromes (Wong et al., 2010). 

Heterogeneity has also limited further determination of the underlying genetics of psychiatric disorder as the empirical genetic data suggest they are overlapping constructs (Cross-Disorder Group of the Psychiatric Genomics Consortium, 2013). Alarmingly, the DSM 5 has been criticized due to potential conflicts of interest, lack of scientific rigor and transparency (including a refusal for an independent review that was endorsed by many mental health organizations), which has led to “The New Crisis of Confidence in Psychiatric Diagnosis” (Frances, 2013). That is not to say that there is no benefit to the current system of diagnoses as it guides treatment and undoubtedly contributes to the improvement in quality of lives in our patients. However, psychiatric syndromes as they are currently defined, result from an incredibly complex and poorly understood interaction of genetics and environment and their etiology remains largely

elusive. Only now, with recent advancements in technology, and the broad understanding that our current definitions of disorders need to be modified, are we ready for a true paradigm shift in psychiatry.

The NIMH funded RDoC project represents a radical change as it attempts to utilize neurobiological measures to rethink psychiatric illnesses as disorders of brain neuro-circuitry along a dimensional model (Insel, 2014).  While the project is still in its early stages, and is currently lacking clinical applicability, the model fits the context of evolutionary theory as natural selection does not shape diseases, but rather selects for traits that render us vulnerable to disease (Nesse, 2011). Proximate and evolutionary understandings of behavior combine in a complimentary and synergistic way and, as Tinbergen suggested, both must be appreciated to truly understand complex behavioral phenomena including psychiatric syndromes. Evolutionary theory allows us to understand why behavior exists and provides the metatheory for the generation of testable hypotheses to guide both research and interventions.

Life History Theory and Evolutionary Mismatch

Life history theory explores how and why organisms utilize time and energy for activities that comprise the life cycle and differential allocation of resources by individuals comprises different life history strategies (Del Giudice & Ellis, 2014).  Life history helps us understand individual differences in behavior and its concepts provide an organizing framework for understanding the development of mental health disorders (Brune, 2014). Life history theory predicts that harsh environmental conditions reduce the amount of parental investment in individual offspring, which in turn biases the offspring towards immediate resource extraction and opportunistic behavior, accelerating biological maturation of offspring, and fostering short-term pair bonds and risky sexual behavior (Belsky, 1991).  This is one explanation that helps us understand why early adverse life events are associated with the development of psychiatric disorders later in life. These events are suggestive of a harsh environment and cue an individual towards a faster life history strategy which has a number of significant consequences including more cognitive resources being devoted towards riskier, emotional behavior as opposed to behavior being guided by higher level cognitive processes; thereby, rendering these individuals more vulnerable to the emotional symptoms that underlie some mental health problems.

This concept is supported by data from humans which suggest that the two most profound structural changes in the brain as a result of early life stress are increases in amygdala volume and decreases in the prefrontal cortex volume (Davidson & McEwen 2012). However, what may have been adaptive at one time in human history may no longer be so due to a number of reasons including evolutionary mismatch (Durisko, 2016). The human environment of evolutionary adaptedness (EEA) is meant to explore the selection pressures in the environment that led to the development of a given adaptation. However it is important to note that EEA "is not a place or a habitat, or even a time period. Rather, it is a statistical composite of the adaptation-relevant properties of the ancestral environments encountered by members of ancestral populations, weighted by their frequency and fitness consequences" (Tooby and Cosmides 1990, 386–7). Each different psychological adaptation will have different evolutionary histories and consequently different EEAs. The majority of human psychological adaptations are thought to have evolved in hunter-gather societies in sub-Saharan Africa as this is where our species is believed to have spent the majority of its ancestral history. As our cultural evolution (technology, medicine) progresses at astounding speeds we are in a constant and dynamic state of evolutionary mismatch. Not only is the way we interact with the world markedly different now than in any other time in human history, but the way in which we interact with each other continues to rapidly change. Perhaps, it is no wonder that the rate of psychiatric disorders in modern society continues to rise as the demands that society places on individuals in no way resembles the life that we have been adapted to live. 

References

1.      Tinbergen, N. (1963). On aims and methods of ethology. Zeitschrift für Tierpsychologie, 20(4), 410-433.

2.      Williams, G. C., & Nesse, R. M. (1991). The dawn of Darwinian medicine.Quarterly Review of Biology, 1-22.

3.      Nesse, R. M., & Williams, G. C. (1996). Why we get sick: The new science of Darwinian medicine. Vintage.

4.      Nesse, R. M., Bergstrom, C. T., Ellison, P. T., Flier, J. S., Gluckman, P., Govindaraju, D. R., & Thomas, M. G. (2010). Making evolutionary biology a basic science for medicine. Proceedings of the National Academy of Sciences, 107(suppl 1), 1800-1807.

5.      Brüne, M., Belsky, J., FaBrega, H., FEIERMAN, H. R., Gilbert, P., Glantz, K., & Troisi, A. (2012). The crisis of psychiatry—insights and prospects from evolutionary theory. World Psychiatry, 11(1), 55-57.

6.      Holtzheimer, P. E., & Mayberg, H. S. (2011). Stuck in a rut: rethinking depression and its treatment. Trends in neurosciences, 34(1), 1-9.

7.      Wong, E. H., Yocca, F., Smith, M. A., & Lee, C. M. (2010). Challenges and opportunities for drug discovery in psychiatric disorders: the drug hunters' perspective. The International Journal of Neuropsychopharmacology, 13(09), 1269-1284.

8.      Cross-Disorder Group of the Psychiatric Genomics Consortium. (2013). Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis. The Lancet, 381(9875), 1371-1379.

9.      Frances, Allen. "Saving normal: An insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma and the medicalization of ordinary life." Psychotherapy in Australia 19.3 (2013): 14.

10.   Insel, T. R. (2014). The NIMH research domain criteria (RDoC) project: precision medicine for psychiatry. American Journal of Psychiatry.

11.   Nesse, R. M. (2011). Ten questions for evolutionary studies of disease vulnerability. Evolutionary Applications, 4(2), 264-277.

12.   Del Giudice, M., & Ellis, B. J. (2014). Evolutionary foundations of developmental psychopathology. Developmental psychopathology, 1.

13.   Brüne, M. (2014). Life history theory as organizing principle of psychiatric disorders: Implications and prospects exemplified by borderline personality disorder. Psychological Inquiry, 25(3-4), 311-321.

14.   Belsky, J., Steinberg, L., & Draper, P. (1991). Childhood experience, interpersonal development, and reproductive strategy: An evolutionary theory of socialization. Child development, 62(4), 647-670.

15.   Davidson, R. J., & McEwen, B. S. (2012). Social influences on neuroplasticity: stress and interventions to promote well-being. Nature neuroscience, 15(5), 689-695.

16.   Durisko, Z., Mulsant, B. H., McKenzie, K., & Andrews, P. W. (2016). Using Evolutionary Theory to Guide Mental Health Research. The Canadian Journal of Psychiatry, 61(3), 159-165.

17.   Tooby, J., & Cosmides, L. (1990). The past explains the present: Emotional adaptations and the structure of ancestral environments. Ethology and sociobiology, 11(4), 375-424.

THE NEED FOR FAMILY INVOLVEMENT IN ASSESSMENT AND TREATMENT

Gabor I Keitner M.D.

Professor Department of Psychiatry

Brown University, Providence, RI

There are many reasons why psychiatrists do not assess or treat families.  Meeting with families is often perceived as not being cost effective given current reimbursement systems.  Equally important is a lack of training for psychiatrists in meeting with families, not only to gather information but also to help them learn how to deal with each other and their loved one's illness. 

Family therapy skills are not part of the “core competency” requirements for residency training programs.  Without proper training working with families can be perceived as being more threatening than working with individuals.

Families have a powerful influence on health equal to traditional medical risk factors.(1) Families can be a reliable source of information about a patient's problems, baseline level of functioning, who the patient is, and how she/he functions in the community. They can provide a longitudinal perspective on the patient's dealings with others and the world. How a patient interacts with his/her significant others and how they in turn interact with the patient, greatly affects the duration of  problems, the likelihood of their resolving or recurring over time.

Problems in the family in dealing with an illness may come to the attention of clinicians in a variety of ways. Patients may be non-adherent with treatment. There may be lack of improvement in spite of following treatment recommendations. Patients may show signs of anxiety and sadness along with feelings of being alone to deal with their illness, not receiving sufficient support or feeling blamed. There may be persistent disagreements and misunderstandings between the patient, family members and treatment providers. Patients may also directly express concern about relationship problems, especially if asked.

FAMILY RISK AND PROTECTIVE FACTORS

There are a large number of family based risk factors that adversely influence the onset and course of illness. These include: poor conflict resolution, low relationship satisfaction, high interpersonal conflict, criticism and blame, intra-familial hostility, lack of congruence in disease beliefs and expectations, poor problem solving, extra familial stress, lack of extra familial support systems, poor organization, inconsistent family structure, family rigidity, low cohesion and closeness, and presence of psychopathology in family members. 

Conversely, there are many protective relational factors. These include: good communications, good problem solving skills, adaptability, clear rolls, achievement of family developmental tasks, mutual support, open expression of appreciation, commitment to the family, extra familial social connections. (1)

Most patients prefer that physicians involve their family in their care. Family members can help patients to  adhere to treatment recommendations. Families can help to keep track of medication side effects and prodromal and residual symptoms. They can assist in sharing responsibilities, lessen the patient's anxieties and facilitate as well as encourage communication between providers. (2)

IMPROVED HEALTH OUTCOMES

Family research clearly demonstrates that working with families of patients is an empirically valid practice.  Family interventions have been shown to be helpful in managing medical illnesses such as hypertension, low back pain, diabetes, systemic lupus erythematosus, and dementia.  Evidence based family interventions have been described for psychiatric illnesses including: alcohol dependence, PTSD, schizophrenia, bipolar disorder, major depression, borderline personality disorder, conduct disorder, ADHD, eating disorders and obsessive-compulsive disorder. (3, 4)

FAMILY ASSESSMENT

The family assessment is the first step in determining both the need for further interventions and the specific areas of family life that might need to be addressed. Family assessment should focus on adjustments related to the diagnosis of the illness, clarification of treatment options, and collaboration in carrying out the treatment plan. A proper assessment should also identify family strengths. The family needs to feel understood, respected, and validated. They do not want to be blamed for their loved one's problems or judged for their perceived deficiencies. It is the job of the clinician to put families at ease and to make them feel comfortable enough to participate openly in the assessment process.

It is important to orient the family to the interview process, so that they know what to expect and to establish an open and collaborative relationship with them. The therapist should ask family members to identify all current problems in the family including the problem(s) that precipitated the meeting. The therapist should then assess ways in which families are organized and function and pay attention to family transactional styles that appears to be related to the presenting problem. The McMaster Model of family functioning is one way to conceptualize family functions and a systematic way of collecting and organizing that information. (5,6)

FAMILY INTERVENTION

There is reasonable empirical evidence that family interventions, as adjuncts to medical treatment, provide benefits to patients and family members above and beyond what they receive from usual medical treatment. Family interventions can be broadly divided into two groupings, psycho educational and relationship focused. 

There is no evidence that one type of family therapy is consistently superior to another. It is advisable to become proficient with at least one approach to assessing and treating families in order to become comfortable with including families in the treatment process. One such approach is the Problem Centered Systems Therapy of the Family. It is practical, clearly articulated and has been tested for efficacy with families of patients with mood disorders. (7)

Some of the common goals of effective family therapies include: increased knowledge about the illness, decreased guilt, redefinition of problems, increased use of adaptive coping mechanisms, improvement of communication skills, problem solving skills and parenting skills, clarification of boundaries, insight regarding current transactions and historical factors, decreased conflict, work on family of origin issues. Family interventions can be implemented successfully at all phases of illness: to prevent disease, to reduce chronicity and to improve functioning in the chronic phase.

Not all families of psychiatric patients are dysfunctional and not all families need family therapy.  In fact, many families deal very effectively with recurring, chronic and severe illnesses. Even well-functioning families, however, can benefit from information about the illness, validation of effective ways of coping, and reinforcement of resilience in the face of major stresses.  Being clear about what constitutes functional or dysfunctional families and about normal versus pathological ways of dealing with difficult situations is an important base from which to be able to evaluate the functionality of any family. 

Meeting with families to assess their ways of dealing with an illness, to provide information, to provide support and to enlist their participation as collaborators in the treatment process should be a routine part of psychiatric care.

References.

1. Campbell, T. L. (2003). The effectiveness of family interventions for physical disorders. J of   Martial and Family Therapy, 29(2), 263-281.

2.Fisher L: Research on the family and chronic disease among adults: Major trends and directions. Families, Systems, and Health 2006;24:4:373-380.

3. Hartmann M, Bazner E, Wild B, et al. (2010). Effects of interventions involving the family in the treatment of adult patients with chronic physical diseases: a meta-analysis. Psychother Psychosom 79:136-148.

4. Heru A.M. (2006). Family Psychiatry: From Research to Practice. Am J Psychiatry 163(6):962-968.

5. Ryan CE, Epstein N, Keitner GI, Miller I, Bishop D: Evaluating and Treating Families:  The McMaster Approach.  New York, Routledge Taylor & Francis Group, 2005.

6. Keitner GI, Ryan CE, Epstein NB (2006). Family assessment. In: Goldbloom D (ed). Psychiatric Clinical Skills. Mosby Elsevier, Maryland Heights, MO pp 327-338.

7.  Keitner GI, Heru AM, Glick ID (2010). Family Assessment; Clinical Manual of Couples and Family Therapy. American Psychiatric Publishing, Washington, pp 63-92.