The voices told him that he was God, and Oliver believed them. Only 17 years old, he was a special, chosen, supreme being, whose wisdom and intelligence were incomparable. Psychiatrists, however, called these voices auditory hallucinations, his first psychotic episode. He was soon diagnosed with schizophrenia. Over the next five years, Oliver spent weeks in psychiatric hospitals and hospitals in the north of England where he lived. When he was deemed too aggressive for one facility, he was sedated, stuffed into the back of a van, and taken to a facility with a stricter regime. Oliver felt overwhelmed and heavy as he fell to Earth.
Five years have passed. Despite being unemployed, Oliver is now able to live at home with his wife and young daughter. He takes clozapine, an antipsychotic given to patients who do not respond to two first-line drugs, such as olanzapine and quetiapine. It's a last resort for one reason: Clozapine is a toxic drug that lowers the number of white blood cells in his body, which is why Oliver has regular blood tests to make sure he's not immune-compromised, a problem that's worsened during COVID. -19 pandemic.
I haven't seen Oliver all this time. I know what is happening to him only through his father, my uncle. We are cousins, only two years apart in age, but Oliver and I have experienced different - often opposite - cases of mental illness. While Oliver felt elevated, I felt worthless, guilty of ruining the lives of others. Far from heaven, I felt I'd rather die and be buried. These suicidal thoughts, combined with lack of motivation and baseless guilt, are typical of the mood disorder depression. Accordingly, doctors prescribed me antidepressants that regulate the neurotransmitter serotonin in my brain, not clozapine or another antipsychotic that works on another brain chemical, dopamine.
I have never been hospitalized or injected with sedatives (although I have been prescribed them). I never heard voices in my head. From symptoms to treatment, my depression is an abyss, except for Oliver's schizophrenia. I have a mood disorder, not a psychotic disorder. Like the animal-plant split in biology, these two fundamental categories have been a cornerstone of psychiatry since the work of the German psychiatrist Emil Kraepelin in the late 19th and early 20th centuries. His textbooks laid the foundation for DSM-5 and ICD-11, the latest editions of two reference manuals published by the American Psychiatric Association and the World Health Organization, respectively, which are used by psychiatrists to diagnose hundreds of different mental disorders, each grouped into about 20 categories: disorders personality, psychosis, psychoactive substances. use, anxiety, depression, food, sexual dysfunction and so on.
Since the publication of the DSM-III in 1980, psychiatric diagnosis has helped select the right treatment for a person's symptoms. It also made possible the tracking of diagnoses across time and space, a field known as "psychiatric epidemiology". However, while these diagnostic manuals may be helpful to physicians who have to make day-to-day decisions about care and treatment, some critics argue that diagnostic systems have actually stifled the development of psychiatry. While deaths from heart disease, cancer, and stroke have dropped dramatically in other areas of medicine, psychiatry has not. As a paper from 2013, "mortality has not declined for any mental illness, prevalence rates have also not changed, there are no clinical tests for diagnosis, detection of disorders occurs well after the generally accepted onset of pathology, and there are no well-designed preventive interventions." In short, psychiatry is stuck.
Perhaps this is due to the fact that the diagnostic system is faulty. Indeed, the fact that about half of patients with one mental disorder also qualify for a second disorder has been well documented since the 1990s: major depression and generalized anxiety disorder (GAD), substance use disorders, and attention deficit disorder with hyperactivity (ADHD). , bipolar disorder and schizophrenia. Either mental disorders really tend to accumulate or, more likely and more disturbingly, our classification system draws lines in unnatural places, carving nature away from its junctions.
There is an alternative approach. A growing group of scientists believe that focusing on one or two diagnoses in a study—as is common in psychiatric research—means that the true nature of mental disorders remains hidden. They claim that in order to
To understand what a brain disorder actually is, you need to scale it down. Looking at the full spectrum of psychiatric possibilities reveals similarities in symptoms, brain circuits, and genetics. Throwing off the shackles of diagnostic classification, there is growing evidence that all mental disorders are in fact the product of one underlying dimension, a general predisposition to psychopathology. This theoretical concept, known as the "p-factor", opens up important new ways to treat and prevent mental disorders.
The P factor also raises the question of whether Oliver and I are really more alike than a cursory glance at our symptoms might suggest. We may share the same underlying vulnerability, but certain life experiences have influenced how it manifests itself. Had my experience been different, perhaps the depression in my mid-20s might have developed into psychosis in my late teens. And if all of this is true, is it possible that Oliver's experience and mine will merge in the future? Unlike diagnosis, the p-factor is a new concept in psychiatry. The article most commonly cited as its foundation was published in 2012 by Benjamin Lahey, a psychologist at the University of Chicago, and colleagues. Studying the symptoms and prognosis of 11 psychiatric disorders in 30,000 people, they found that the distribution of diagnoses was mainly determined by two known groups or dimensions to child psychiatry since the 1960s: internalization (turning inward and separating into fear and distress) and externalization ( physical appearance and sometimes explosiveness, including substance use, conduct disorder, and ADHD). It is important to note that even disorders classified as internalizing or externalizing often overlap.
“In our culture, we can expect people who experience one fear to experience other fears, and people who fear being unhappy, and so on,” wrote Lahey and his co-authors. "It seems less likely that people in our culture expect antisocial people to also be anxious, afraid, sad and guilty." However, that was exactly what their data implied. And the statistical model that best explained the data assumed a “higher order” vulnerability factor common to these two categories of mental disorders. When this factor was removed from the models, the correlations between groups became weaker, suggesting that it was responsible for the frequent simultaneous occurrence of externalizing and internalizing disorders.
In 2014, a study by Avshalom Kaspi, a psychologist and epidemiologist at Duke University in North Carolina, and colleagues went further, showing that so-called “thought disorders” (schizophrenia, mania, and obsessive-compulsive disorder, or OCD) also correlated with externalizing and internalizing disorders through shared responsibility. This expanded on the original concept of the p-factor, suggesting that it applies not only to ordinary mental disorders, but to all mental disorders.
Mathematical models can work with huge data sets and find patterns that the human mind would not even take into account. But they are not impartial. They have built-in biases of their own. In the case of the p factor, critics have accused Kaspi and his colleagues of using models that are prone to overgeneralization, i.e. exaggerating overlaps between disorders. In 2017, psychologist and statistician Riet van Bork of the University of Amsterdam wrote: "We already knew, even before Kaspi and his colleagues began their research, that they would arrive at a common factor by virtue of mathematical necessity."
Whether they wrap themselves in a strong chrysalis or grow wings to fly, they are still the same person.
Because current diagnoses share several common symptoms — insomnia, irrational thoughts, or bad moods, for example — van Bork thinks they should be correlated with each other, and the computer model simply captures the positive correlations that already exist internally. psychiatric classification. Using the analogy of water quality and biodiversity, van Borky and her colleagues argued that biologists do not study the overall factor of "lake health". "Instead, biologists are relying on a more plausible explanation for such data: higher water quality provides more diversity of life, and more lives will improve water quality." They added that in the case of psychiatric disorders, the positive correlation between symptoms could be explained by a similar web of relationships without resorting to the p-factor: one symptom leading to another, a flourishing of anxiety unleashing the seeds of substance use disorder or depression; the usual experience of guilt in depression creates fertile ground for
paranoia or psychosis.
Undeterred, in 2020 Kaspi and his colleagues, including his wife, clinical psychologist Terry Moffit, published a study that did not require computer models to detect the unity of mental disorders - this was visible in the data to the naked eye. The study was based on data from a recent round of surveys of nearly 1,000 people, now in their 40s, born in Dunedin, New Zealand, whom Caspi and Moffitt have been following since the 1980s. The lives of these people paint a rich picture of lifelong mental disorders. What once seemed like a static diagnosis has evolved into a subtle reshaping of symptoms that provides amazing p-factor support. Years of consistent research shows that depression develops into substance abuse and anxiety; "ADHD in childhood has led to a thought disorder like schizophrenia in adulthood." Even depression and psychosis are reversed. If there is an analogy between biology and psychiatric diagnosis, it is not in the split between animals and plants, but in species that metamorphose. Butterflies, moths, frogs: they grow, transform and become creatures completely indistinguishable from themselves. But regardless of whether they wrap themselves in a strong chrysalis or grow wings for flight, they are still the same individual.
For Caspi, the shapeshifting or "serial comorbidity" seen in the Dunedin cohort confirms the existence of a common responsibility underlying all mental disorders that can sprout at different times in our lives. Critics may question the generalization of the New Zealand data, but there is strong converging evidence from elsewhere. For example, a 2019 longitudinal study that used over a century of data from Danish health registers found similar patterns in serial mental health diagnoses over the lifetime of almost 6 million people. Importantly, Kaspi found that psychiatric disorders that first appeared in childhood or adolescence were much more likely to exhibit this pattern of consistent comorbidity.
Keep in mind, however, that epidemiological studies over the past three decades show that more than three-quarters of all mental disorders occur before the age of 25, making the p-factor concept applicable to most people with mental health problems. Early onset also predicts more severe and difficult-to-treat conditions, suggesting that early intervention can be a powerful way to prevent patients from developing long-term health crises and save health systems from dependence on costly and imperfect treatments. If the p-factor is the common seed of adult psychopathology, what if a more general approach to prevention could prevent it from taking root?
The first mental health crisis happened when I was 15 or 16 years old. I sat on the cold stone steps of our old farmhouse in the middle of nowhere in the north of England. End of the world, I couldn't breathe. I was confused and my thoughts turned to death. It was a panic attack. I also remember sitting in the doctor's office with an unrelated health problem and suddenly burst into tears. Looking back, I realize that this was a moment when my mental health could have been directed towards a more stable future.
However, instead of talking to a therapist about issues at home—my mother's drinking, her poor mental health, my father's struggles to find work, our isolation from friends and family, my disruptive behavior at school—I was simply branded a hormonal disorder. teenager. Over the next few years, my symptoms seemed to dissipate as I took A-levels and moved on to university to study biology. However, after graduation, my parents separated, the family home was sold, and my first serious girlfriend broke up with me. Living in a hostel in south London, my panic attacks returned, and the depression that had been dormant began to deepen. The charm of suicide resurfaced.
Six years later, a bewildering mixture of symptoms still come and go like weather storms: the bright light of anxiety, the chilling darkness of depression, the torrent of rage that rips through my brain circuits and leaves me as an embryo.
My most recent mental health crisis, including recurrence of suicidal thoughts, happened in February 2021. The psychiatric team was surprised to hear from me again - at the end of 2019, their assessment of my mental health was overwhelmingly positive. After several phone calls and new examinations, I was advised to return to psychotherapy and significantly increased the amount of medication prescribed to me. Nar
poison with antidepressants and anxiolytics (drugs that fight anxiety), a consultant psychiatrist wrote to me suggesting antipsychotics to help me stay stable. After reading his recommendation a few days later, I thought of Oliver again. If we are prescribed the same drugs, then we are fighting a common enemy? Do our opposite symptoms hide a common inner vulnerability?
Wanting to learn more about the p-factor, I recently contacted several researchers I met and consulted while writing my book on treating depression, A Cure for Darkness (2021). “This [p-factor] is a very interesting topic,” said Myrna Weisman, an epidemiological psychiatrist at Columbia University in New York, before admitting that the field is still in its infancy. "More show business than science," another (who didn't want to be named) replied, before adding, "There are some general ways that link disorders to each other, but that's like saying there are many physical disorders. that are associated with inflammation and are linked to each other through this common mechanism. This is true, but only a tiny part of the story.
I see the logic behind this last criticism, but it doesn't completely convince me. While bodily immune disorders vary in their symptoms and location in the body—whether it be the gut (Crohn's disease), the pancreas (diabetes), the joints (rheumatoid arthritis), or the skin (psoriasis)—all psychiatric disorders are primarily disorders brain. What's more, by studying the activity of discrete neural circuits, neuroscientists have found a striking concordance between mental disorders. For example, a meta-analysis from 2018 found that connections between brain circuits involved in vision, internal thinking, and motivation are equally hyperactive in many common mental disorders. How we perceive the world (vision) and how it is translated by the brain seems to be a major component of mental disorders. According to the researchers, the overall p-factor "may lead to more labor-intensive or less efficient processing when internally generated thought and externally generated sensory information compete for attention." In fact, the same brain circuits have been targeted for psychedelic therapy, which may help explain promising trial results using psychedelics to treat a range of disorders, from depression and anxiety to post-traumatic stress disorder and alcoholism.
A similar story unfolds in the human genome, where there is a significant amount of overlap between genetic risk factors for mental disorders. In 2009, a landmark study of data from the Swedish National Registry found that bipolar disorder and schizophrenia share many common genetic risk factors, a study that helped refute Kraepelin's notion of a clear separation between psychotic and affective disorders. In 2015, the same research team at Karolinska Institutet expanded their sample to include eight mental disorders, again finding a common genetic factor linking them.
These data appear to provide further support for the p-factor. But overall genetic risk between conditions isn't everything. Only 10 to 36 percent of susceptibility to mental disorders is associated with common genetic risk factors. The rest of the differences between psychiatric disorders were due to unique genetics (for schizophrenia and bipolar disorder) and separate non-genetic environmental factors (for mood and anxiety disorders). This led the researchers to conclude that the p-factor could represent something as general as "general distress or impairment". All mental disorders are stressful and can be debilitating. Is the p-factor just a statistical measure of human suffering or "life hard" as some critics claim?
Associating a p-factor with harsh conditions should not be misinterpreted as a way to blame parents.
Kaspi, himself a common factor in many p-factor studies, counters that this explanation is not a criticism at all. He believes that a harsh, unpredictable childhood environment is a common knot of mental illness. “If you look at each disorder, you will see that at the core of each disorder is some kind of aberrant way of seeing or seeing the world,” he says. "It's a paranoid idea." There is a boy who thinks everyone is out to get him and is later diagnosed with a conduct disorder. A skinny girl who looks in the mirror and thinks she's fat is an eating disorder. A teenager who considers himself guilty of quarrels of parents and drunkenness - depression.
"One of the most interesting origins of most
this erroneous thought is due to harsh, inconsistent and unpredictable early conditions,” Kaspi tells me. “Those kinds of experiences that create the expectation that something bad will happen, or they create the expectation that you will be rejected, they create the expectation of violence, they create the expectation of constant threat and that something will go wrong. Things, you know, never change. And so it gets out of control. So I think a lot of it has to do with what these early experiences do—they distort our expectations about the future. That's why they are so important."
It brings up moments from my past that are still surfacing to this day. My mother struggled with depression and alcoholism. For most of the day and evening, she was unavailable, both emotionally and physically. When confronted with her, she became irritable, explosive, and threatened suicide. When I started having panic attacks, I felt like I was being punished rather than listened to or supported. Today, as a parent, I try to remember the trauma of my mother's past—the loss of both parents to lung cancer, the memory of her mother being institutionalized—and how it affected her behavior. In understanding there is forgiveness.
It's hard to say how Oliver experienced his upbringing, but he grew up in a stable family without addiction or separation. He had a hard time at school, but so did many children who didn't have a psychotic episode. I know that his parents are doing everything they can to help him with his medications and life outside the institution. Oliver's story is a reminder that linking the p-factor to harsh conditions should not be misinterpreted as a way to blame parents. This is not a reformulation of the "refrigerator mother" theory of autism or the schizophrenogenic mother theory for psychosis that gained currency in psychiatry in the 1950s. Many difficult experiences can happen outside the home. For example, bullying is a common risk factor for early psychosis. Moreover, difficult childhoods are often the result not of bad parents, but of the social system that failed them. Unemployment, poverty, emotional neglect, domestic violence: these are common factors that underlie a variety of mental disorders, and each is exacerbated by the stresses caused by the COVID-19 pandemic.
p - factor remains unknown. It's like the dark matter of psychiatry: a power that can only be seen by its effect on things we can measure. In this case, the symptoms, genetics and brain activity. It has a gravitational semblance that seems to tie these visible elements together.
The p factor may turn out to be nothing more than a statistical artifact. But if there is any value in his concept, it is in raising the possibility that targeted interventions in childhood—prevention of abuse, effective treatment of parental mental disorders, and lessons in cognitive behavioral therapy in schools—could reduce the incidence of the most severe mental illness. disorders that diversify and become disabled throughout a person's life. With a young daughter at home, I will continue to adjust my medications and try to find a therapist to help me live a healthy life without them. Now it is not only about my own health and well-being, but also about the future of my daughter.