Jordan Smoller: "The Other Side of Normal: How Biology is Providing the Clues to Unlock the Secrets of Normal and Abnormal Behavior"

MS. DIANE REHM

11:06:56
Thanks for joining us. I'm Diane Rehm. Phobias, anxiety, obsession, depression, Harvard psychiatrist Jordan Smoller says more than half of all Americans have met the criteria for a psychiatric disorder at some point in their lives. He argues mental illness is a variation of the same brain systems that help us cope with everyday life. In a new book, he says in order to understand abnormal behavior, we must start by understanding the biology of normal.

MS. DIANE REHM

11:07:34
His new book is titled "The Other Side of Normal." Jordan Smoller joins me in the studio. You're welcome to be part of the program. Call us on 800-433-8850, send us your email to drshow@wamu.org, feel free to join us on Facebook or Twitter. Good morning to you, sir.

DR. JORDAN SMOLLER

11:08:01
Good morning, Diane.

REHM

11:08:02
Good to have you here, Dr. Smoller. That sentence I used was a quotation from your own book. I'm going to repeat it because it really struck me. You say by the latest counting, more than half of all Americans meet criteria for a psychiatric disorder at some time in their lives. Now, I guess first, we'd have to define psychiatric disorder and second, we'd have to define length of time you're talking about because somebody could be depressed for a week. Somebody could obsess for a week. Would you put that person in the category as having a psychiatric disorder or would that person be considered normal with a passing psychiatric disorder?

SMOLLER

11:09:16
That's a good question. Actually, the examples that you gave would not be considered disorders, and in fact, the current criteria for depression require that you have at least two weeks of depressed mood, or really a loss of interest in the things that normally make you happy, but also have a number of other symptoms that really persist, and these are not passing kinds of moods, but these are things that happen day after day for some period of time. Obsessing and Obsessive Compulsive Disorder, similarly, these are long-standing kinds of things for most people.

SMOLLER

11:09:56
But it does get to the point about where do we draw the line? Where do we say that something crosses over between what we expect in the vast range of normal behavior to something that we could call a disorder? And modern psychiatry has an answer to that, and actually has criteria for defining that line. A key component of it is, does this thing interfere with your life? Does it cause suffering and impairment, and that's basically the line that we draw for many of our disorders.

REHM

11:10:32
And surely there's not one of us who cannot say that at some point in our lives, either by grief or sadness or anger or obsession, our lives have not been interrupted.

SMOLLER

11:10:52
Yes, that's true. And one of the things overall that's so complicated about this area is that many of these things are very familiar to us, depression, anxiety and so on. They're so much a part of our lives, and in fact, in some ways they're part of human nature. And the current system for diagnosing these things does rely on a consensus of experts essentially. We have over time constructed definitions of these disorders, but one of the things that I argue in the book is that when we're relying on focusing on drawing these lines and what's abnormal, what's unusual, bizarre, but without tying it to what we understand about the range of normal, this vast distribution of what the human mind and brain are capable of, we end up sometimes with definitions that we're uncomfortable with, or that are unstable.

SMOLLER

11:11:47
Things that end up seeming either to pathologize normal, or that we have a totally different view of at other times.

REHM

11:11:58
Take one of the biggies. At one point, homosexuality was thought to be abnormal. Is it considered abnormal any longer?

SMOLLER

11:12:13
No, you're right. That actually until 1973, the American Psychiatric Association recognized homosexuality as not normal, and, in fact, it was a vote of the Board of the organization that eliminated it from the diagnostic manual and we now sort of look back at that with some bewilderment about how that could even be thought of as a disorder, per se. But this is a process that sort of continued over the last 30 years as we've sort of tweaked our understanding of what makes sense.

SMOLLER

11:12:50
And we've recognized there were dramatic findings early in the '70s and in the early '80s that suggested there was something really not quite right about how people were understanding and using psychiatric diagnosis. So for example, there was a famous study where a psychologist brought volunteers into a psychiatric hospital who were normal, and asked them to say that they were having some kind of symptom, they were hearing a thud. And then their job was to convince the staff to discharge them by being normal. It took a long time for them to get discharged, and every single one of them was diagnosed with schizophrenia.

SMOLLER

11:13:32
That was a wake-up call. And then there were some studies that showed that whether you got a diagnosis of, say, schizophrenia or bipolar disorder mattered a lot about were your psychiatrist was. In the United States, the same person might be likely to get a diagnosis of schizophrenia or borderline personality disorder. In the UK they were more likely to be diagnosed with manic depressive illness. So there was some lack of common language. And what happened in 1980 was a real watershed.

SMOLLER

11:14:01
The system was sort of overhauled, and we had the beginning of what we now have as a diagnostic manual, the DSM as it's called, and the advance there, and it was an advance, was to provide a common language for diagnosing these disorders, and that was something that psychiatry hadn't had. So at least we were using the same criteria, and that allowed us to begin to study things. The problem was, that was a start, and it became sort of -- and people colloquially call it the Bible, but really I think people recognized from the beginning that we really need to kind of iteratively improve this.

REHM

11:14:40
So what you're trying to point out is that psychiatry has in some ways neglected the consideration of what is normal by virtue of putting too much emphasis on what is abnormal. Is that fair?

SMOLLER

11:15:02
That's right. Yes. Well, I think that the goal for what we need to do in the coming years is to begin with an understanding of normal. What is the brain designed to do, how does it function, and really, my argument is, only by understanding normal can we make sense of the abnormal, and that, as we've just been talking about, is a different view that psychiatry has generally taken for the last hundred years.

REHM

11:15:26
So I would gather that psychiatrists would believe that normal runs a huge range, just as one would say depression runs a huge range. So where on that arc is normal?

SMOLLER

11:15:49
Mm-hmm. Well, one of the things that we've been learning is that as you mentioned earlier on, there are no bright lines, so we can't in fact say as a factual matter where one crosses over to the other. And I use the example in the book of night and day. So these are two things that we understand are different. They're different states. They're meaningful. We organize our lives around them, but exactly where night becomes day or day becomes night is sort of an arbitrary decision at some level, and yet they're real things, and we're comfortable with that, with the fuzziness of twilight as I say.

SMOLLER

11:16:24
And so at some level, we do have to recognize that if we're going to draw boundaries, they will be requiring some kind of a judgment. But the most sound way for us to do that, I argue is to really have a sense of starting from the bottom up, getting a basic map of how the mind works, and it's, you know, in fairness, it really hasn't been possible until recently to do this because our knowledge, our tools, have been somewhat limited.

SMOLLER

11:16:52
We now have advances in neuroscience and genetics and evolutionary biology. A real convergence of science that's beginning to fill in this map, and that is a fascinating prospect I think.

REHM

11:17:03
Of course, there was a piece on "Morning Edition" this morning, which you may have heard where a man who had been diagnosed as autistic from the age of 10 had allowed himself to become a subject in brain research, so that with PET scanning, CAT scanning, one could see the images of the brain at work. Is that what you're talking about when you say we have so many more tools now to understand the difference perhaps between what is normal and abnormal?

SMOLLER

11:17:51
Yes. I think that we do have an enormous array of tools that really weren't available in the last two decades. I mean, they've only become available, and that includes a remarkable alphabet soup of all kinds of imaging technologies, MRI and CAT scans and PET scans and a whole other series of them, that allow us to look at how the brain develops, what its structure is, what its function is, and we also have advances in genetics that allow us to look at how do genes play a role in this disorders, but I wouldn't say that it's all reducible to some biological chemical. We need to understand biology, but also psychology, and it's complicated.

REHM

11:18:34
Jordan Smoller of Harvard University. His new book is titled "The Other Side of Normal." Short break here. Stay with us.

REHM

11:20:05
And welcome back. Jordan Smoller is with me. He is an associate professor of psychiatry at Harvard Medical School, also associate professor in the Department of Epidemiology at Harvard School of Public Health. His new book exploring how biology is providing clues to unlock the secrets of normal and abnormal behavior is titled, "The Other Side of Normal." Do join us by phone, 800-433-8850.

REHM

11:20:50
Send us your email, join us on Facebook or Twitter. Here's an email from Eloise, who says, "what about undiagnosed mental illness recognized by others but denied by the person who has it?"

SMOLLER

11:21:12
Yes. This is a challenge for families and friends of folks who are suffering and who may not see either the opportunity for help or the potential for getting help. And it's often very difficult. And that is a challenge that we face all the time clinically. It's obviously very important to try to help people feel supported and help them see that if they feel that something is not right or they're not happy with way things are, there may be some benefit to at least finding out what some of the options are.

SMOLLER

11:21:57
But the reality is that in some cases, some of the symptoms and difficulties that people have when they're suffering from psychiatric disorders make that a real challenge. And there are limitations sometimes with what we can do.

REHM

11:22:09
Here's a tweet, "how does one determine what is normal and not simply an individual trait?"

SMOLLER

11:22:20
Yes. Well, one of the things that I argue in the book is that we, you know, we talk about normal and abnormal all the time. We often don't exactly know what those words might mean. And sometimes we think of normal as the absence of something abnormal, which isn't terribly helpful. And my argument is that normal is not a point or an ideal or the average. It's really a vast spectrum of human possibility.

SMOLLER

11:22:47
And many of the things that we thing of psychiatric disorders are in fact extremes or exaggerations of traits and systems and mechanisms that we use to handle everyday life. Fear and anxiety are a great example of that. Here's something that we all experience. It's part of human nature. And the reason for that is that our brains evolved to be able to detect danger and avoid harm. It's so important we have circuits in the brain devoted to these things. But many of the things that we refer to as anxiety disorders are exaggerations of those same brain systems. They go awry and they can cause real suffering.

REHM

11:23:25
One could argue that falling in love could be a manifestation of taking something to an extreme and feeling a little nutsy because of it. Do you agree?

SMOLLER

11:23:46
Well, I think falling in love is obviously one of the joys and wonderful things about being human. And it is true that when you're in love you see the world differently. And it's true that we know actually a little bit about some of the brain chemistry and some of the psychology of what goes on there. We know something about some of the circuits in the brain that are activated when we fall in love. They have to do with some the same things that make us find lots of things rewarding.

SMOLLER

11:24:15
And these reward circuits are the ones that get hijacked by street drugs, for example. And it's almost being under the influence when you're in love. But that is certainly not a disorder. We do see -- and one of the clues to this fluidity between normal and abnormal is that we see some of the things that we might recognize as symptoms or problems flaring up normally at different times in our lives.

REHM

11:24:39
Give me an example.

SMOLLER

11:24:39
Falling in love is one of them. But another one is when parents have children, when women are about to give birth and shortly after the birth, and fathers as well, we see a flaring up of kind of obsessive compulsive thinking. People have obsessions about the harm that might happen to the child. They even sometimes have thoughts that they might do something terrible and cause harm to the child.

SMOLLER

11:25:02
And we see that about 70 percent of parents around that time have these kinds of intrusive, almost obsessional and compulsive kinds of behaviors. That's not abnormal and it's something that kind of goes away as the child goes on to develop. And you learn that things are safe. But I think it's a clue that we have in all of us these systems that are trained to solve certain problems and making sure that your child survives and does well has always been really important to us as humans.

SMOLLER

11:25:38
So we have systems dedicated to that. And those systems really go into overdrive at some times in our lives. But when it crosses the point where by itself those symptoms and obsessions and compulsions can take over the mind and interfere with and sometimes destroy our lives that's clearly something else.

REHM

11:25:58
So, if I were anxious and begin to be concentrating on my anxiety and you were to image my brain in the midst of that anxiety and perhaps acting out in those ways, how different would my brain look from that of a normal, quote, "person" who is not experiencing anxiety?

SMOLLER

11:26:37
Mm-hmm. Well, I would say you are normal if you were feeling anxious because it's a part of normal life.

REHM

11:26:42
Exactly.

SMOLLER

11:26:42
But we do know that when people are feeling fear and anxiety certain regions and circuits in the brain kind of light up if you look at them in a neuro-imaging kind of context. And there is a key network that is centered on something called the amygdala. It's a small structure sort of deep in the brain that is really important for us attaching significance to things, recognizing that something's important.

SMOLLER

11:27:09
I need to pay attention to it. I need to learn to fear it if it's dangerous. But then there are parts of the cortex, the higher parts of the brain that get involve and kind of regulate how active that amygdala responses. And then another part of the brain called the hippocampus, which helps us to learn whether something needs to be feared and remembered or is actually safe. And so, this network, which also involves a few other structures in the brain is something that we see get activated in normal anxiety and get more strongly activated when people have anxiety disorders.

SMOLLER

11:27:47
Things like phobias and panic disorder and post-traumatic stress disorder. And one of the fascinating things about understanding the biology of normal is that it may actually let us develop more effective treatments for people who suffer. So, the stark reality is that many of the treatments we have for psychiatric disorders, whether they're medications or psychotherapies, emerge from insights that are about 40 years old.

REHM

11:28:13
Yeah.

SMOLLER

11:28:13
We've had advances and different drugs have come out and therapies have been tweaked, but most of it has been based on these older insights. One of the things that we're seeing is that by understanding what the basic biology is, we can approach things in a different way. And fear and anxiety is one great example of that. So it turned out that people had a pretty good understanding over the last 10 or 15 years about the biology of how we lay down emotional memories, fear memories.

SMOLLER

11:28:42
It involves a circuit, the one that I just described. And by understanding that, scientists were able to hypothesize that we could maybe actually turbo-charge psychotherapy.

REHM

11:28:57
What does that mean?

SMOLLER

11:28:58
Well, the most effective therapy for anxiety disorders is something called cognitive behavioral therapy. And what it involves is sort of a re-learning and desensitization to the things that terrify us. And you learn that they Are actually not as dangerous and fear-inducing as you had previously thought. And through that process you extinguish your fears. Well, by understanding how that fear extinction works, some psychiatrists and neurobiologists thought, well, there's a drug that actually mimics the neurotransmitter involved in that learning process.

SMOLLER

11:29:35
What if we could give that while people were taking -- we undergoing psychotherapy, could we actually boost the learning that helps people get over their fears. And what's remarkable is this is a drug that actually was originally developed for tuberculosis. It's an antibiotic. And there have now been several studies suggesting that if you take this an hour before a therapy session for panic disorder, anxiety disorders, a number of other conditions, it can accelerate and perhaps boost the effectiveness of this learning that goes on in psychotherapy.

REHM

11:30:10
Tell me about what's happened to the change of diagnosis and characterization of autism. That's happened only recently, and I think there are lots of questions about that. How does that fit into the other side of normal?

SMOLLER

11:30:33
Right. Well, a couple of things I would about that. One is from the perspective of how we understand and make sense of something like autism, understanding again what the brain was designed to do gives us some important clues. So at some point in your childhood, when you were about two years old, let's say, you began to learn that other people have their own thoughts and beliefs and feelings that are different from yours.

SMOLLER

11:30:57
And scientists call that having a theory of mind. And that's a fundamental social cognition tool that is important to all kinds of relationships. And it's so important that we have circuits in the brain that really are specialized for handling these things. One of the things that seems to go awry in autism is the development of that capacity. And so, rather than seeing this as sort of a very mysterious disconnected kind of syndrome or set of symptoms, we can see how it emerges from these systems that we all use to navigate social life.

SMOLLER

11:31:34
The controversial aspect or one controversial aspect of autism is that we've seen this growing prevalence, this epidemic that some people have seen. And the answer to why that is is still not entirely known. Most people think it does have something to do with how we draw these lines between normal and abnormal. So autism was first described in the 1940s and it was a much narrower definition.

SMOLLER

11:32:02
Over the 1980s and so on, we found that other conditions or degrees of social and communication impairment sort of continuous with or on the same spectrum. It got more broadened. People became much more aware of it. And so, to some degree, there was more recognition. Whether that explains this increasing trend entirely is a matter of a lot of debate and there are unanswered questions about whether there may be things in the environment or even things having to do with the age at which people have children that may be contributing at a sort of biological level to why we see this.

REHM

11:32:42
Jordan Smoller, his new book is titled, "The Other Side of Normal." And so back the two-year-old and the development of, quote, "having a theory of mind." What you're saying is that the child becomes aware that he or she is not the only person having thoughts that others have thoughts that may be different from or behaviors that may be different from. But something stops in that child's understanding of or awareness of that fact.

SMOLLER

11:33:30
Well, in the case of autism spectrum conditions, it does seem that a fundamental sort of element of what goes awry is the development of that capacity, that there are limitations or a delay in an ability to take other people's perspective, to sort of project yourself into the minds of other people and understand their feelings or attend to them. And, you know, there's a broad spectrum of this.

SMOLLER

11:33:56
And, in fact, one of the surprising things that people have found is that these traits that we think of as autism spectrum traits are actually distributed in the population, they vary. We all have varying degrees of them. And in fact, some of the genes that have -- that appear to contribute to autism, the risk of autism seem to -- at least this is from twin studies -- be overlapping with genes that explain or contribute to variation in these kinds of social skills or social cognitive skills in the general population, in all of us. Another example of how drawing that line is really difficult.

REHM

11:34:34
We have a number of callers, so let's open the phones. First to Kansas City, MO. Good morning, Maggie, you're on the air.

MAGGIE

11:34:45
Hi. I was wondering, given the fact that DSM is becoming a little (word?) and trying to match it with the neuroscience of disorders, is there room for culture still in the definition of what is normal?

SMOLLER

11:35:04
That's a really interesting question. Actually the DSM, as you may know, it's been in the headlines a lot recently. There is a new revision of it underway. And that revision is making some changes, largely they're still based on this model of trying to define syndromes. And ultimately, based on a consensus of experts, there is a move now towards -- and the National Institutes of Mental Health has begun an effort to do what we've been talking about, which is to start with a sort of a bottom-up understanding of how the mind works.

SMOLLER

11:35:37
And I think in many instances we recognize that culture does matter in terms of how we express, de-stress, how we understand what is problematic or not. And culture obviously, if you think about people, for example, who are very shy, extreme shyness in the -- when it takes the form that it interferes with social relationships and debilitates people to the point that they can't look for a job, they can't have dates and so on, we sometimes call that a disorder, social phobia.

SMOLLER

11:36:10
But of course some of that has to do with the way our culture and society are organized. And there is this inescapable value judgment element of when things cross the line to being impairing. And so, our understanding of how to draw the line does in fact depend on culture. We also see certain conditions in other cultures that we don't necessarily have a system for in our own American system.

REHM

11:36:39
Such as?

SMOLLER

11:36:40
Well, one of the examples I give in the book is a problem that actually was described for centuries in China and it's referred to as a culture-bound syndrome sometimes because you don't see it widespread in some other parts of the world, although increasingly we are. And this is a condition in which men have a panicky fear that their genitals are going to retract and that if that happens, they would die.

SMOLLER

11:37:07
It's something called koro. And one of the odd things about it is that it can sometimes occur in epidemics where whole villages can be affected. It was initially described in Asia, but it's been seen in Africa and there have been cases in the West as well. It doesn't exactly fit with anything that we have in our American system.

REHM

11:37:26
Jordan Smoller, the book is titled, "The Other Side of Normal." Short break here. And when we come back, more of your calls, comments, questions. Stay with us.

REHM

11:40:04
And welcome back. We're talking with Jordan Smoller who is a professor of psychiatry at Harvard University. His new book is titled "The Other Side of Normal: How Biology is Providing the Clues to Unlock the Secrets of Normal and Abnormal Behavior." Let's go now to Cincinnati, Ohio. Good morning, Vicki.

VICKI

11:40:37
Good morning. My question is about something you talked about earlier, homosexuality being taken out of the DSM. But gender identity disorder and other kinds of sexual identity disorders are still in the DSM. So I wanted to know kind of, you know, what you thought about keeping those in the DSM.

REHM

11:41:03
Why is that?

SMOLLER

11:41:04
Well, I think, you know, the whole area of sexual disorders is one that has been obviously inherently controversial. And there's been a lot of evolution in the thinking of and the example of homosexuality is the most obvious one. It also gets back to what one of the earlier questions was about the influence of culture. And it is certainly true that as our understanding of the variety of ways that people express their sexuality has expanded we have come to look at some of these things quite differently. And this is one of the areas that is particularly controversial as the DSM 5, this next edition, is being debated.

SMOLLER

11:41:50
And, you know, this is something where we just have a very incomplete picture of the range of biology and psychology that goes into our understanding of what sexual orientation and sexual identity is. And my guess is that we will see a sort of maturing of that process and a de-stigmatization both outside of the profession and inside the profession of some of these other expressions of sexuality.

REHM

11:42:23
You talked earlier about the votes that had been taken to create the DSM and what goes in, what gets changed, what comes out. How many women are part of that voting group?

SMOLLER

11:42:43
Well, the current DSM process, which I'm not directly involved in, has been an extensive one that has involved work groups in all of these different areas that have been working for years. And what they have tried to do, as far as I understand, is to gather experts in all of these areas. There are many women involved and I know a number of women who are -- have leadership roles in these kinds of -- in the groups that are working on this.

SMOLLER

11:43:10
And it's not quite a vote in the sense of -- that it was in 1973. It's much more a process of debate sifting through the evidence. And then actually there's been a period of open comment where they've received comments from people in the profession and outside the profession. But it is definitely true that the role of women earlier in psychiatry was much more limited. And that probably had an effect on some of the things that people considered normal and abnormal.

REHM

11:43:43
All right. To Long Island, N.Y. Good morning, Sarah.

SARAH

11:43:47
Good morning, Diane. I'm so -- I was just telling your screener, I'm so happy to have this topic being discussed in such an open and, you know, honest form. I've suffered from panic attacks -- severe panic attacks since I was a young girl. I've been through cognitive behavioral therapy and I take daily medication as well as acute medication to control them. And I often find that people will flippantly say, oh I'm having a panic attack or I'm having an anxiety attack and not truly really understand what that feels like.

SARAH

11:44:21
And I know for myself I went for a number of years being very embarrassed and feeling stigmatized that this wasn't a credible disease, a credible, you know, health issue. And I'm learning now to be more open and honest with it and to have someone like you tackle this subject and talk about it. And just the title of the book really, I think, gives hope and confidence to so many of us who are suffering with these types of anxiety disorders, panic attacks, depression, things like that.

SARAH

11:44:56
So I just wanted to say thank you for having this topic on. I know I actually had a panic attack this morning and so hearing this topic today kind of it will make my day a little bit easier to get through.

REHM

11:45:08
I'm glad. I'm glad, Sarah.

SMOLLER

11:45:11
I'm really glad to hear you say that. And I think that, you know, one of the hopes is that as we understand how some of the things that really make people suffer also emerge from these kinds of systems and brain systems that we all use. We learn something about our shared humanity and about what connects us. And we also know, and as you very importantly point out, when you're really suffering with some of the things that can happen as our emotional systems go awry or other things go awry, it is not simply a -- you know, a bout of a little bit of anxiety that we might all feel.

REHM

11:45:47
Right.

SMOLLER

11:45:47
Some of these things can really be disabling. The good news is that the more we learn the more options we have to help folks.

REHM

11:45:55
Sarah, I'm glad you called. Good luck to you. Here's an email from Linda in Frederick, Md. who says, "I'm concerned with the over diagnosis and over medication of teens. There appears to be a sort of temporary insanity that occurs roughly between the ages of 13 and 15. Might not medicating teens during this period halt or stall an essential part of the growth process that turns us into normal adults?" That's a great question.

SMOLLER

11:46:39
It's a very good question and there's a lot of controversy about first of all, when do we recognize psychiatric disorders? Is it possible for a child or a teenager to have bipolar disorder or schizophrenia? And what's the appropriate use of treatments? One thing to know of course is that there are many treatments available, not all of which involve medications. There's also a difference between what the sort of medical take on treatment and diagnosis is and how it may be used in practice.

SMOLLER

11:47:11
And so it's certainly possible that some of the diagnoses that are actually quite valid diagnoses may get overused. Some of them may get underused and there's also evidence that people are under recognizing things that are causing people problems. In the most responsible circumstance, which is what we hope for everybody, the decision about what kind of treatment and when is a matter of weighing the risks and benefits. So I think that, you know, I think everybody would agree that this sort of normal teenage mind, which sometimes can be pretty outrageous, is not something that requires medication.

SMOLLER

11:47:50
When somebody is suffering in a way that is destroying their ability to go to school, their relationships and threatening their future and we can relate that to something we recognize as an illness that can be treated, then I think there really are circumstances where medication can be helpful.

REHM

11:48:08
Here's something from Michael who says, "Given what post traumatic stress victims have witnessed and participated in, are we in the position to call their responses abnormal?"

SMOLLER

11:48:27
That's a really interesting question as well. So the post traumatic stress disorder, another very controversial diagnosis, and it is certainly true that overwhelming trauma is something that is destructive and devastating for people. And a normal response to that -- what we would think of as a normal response can be pretty significant. I mean, people can be anxious, can be terrified, distressed and so on.

SMOLLER

11:48:56
When we talk about post traumatic stress disorder we're talking about something that is persistent and that really can overtake somebody's life. Again, how that diagnosis is used in practice is a different matter. But there is no question, and I've seen this from working with folks with post traumatic stress disorder, that their lives can be overtaken by intrusive thoughts, nightmares and inability to form relationships and so on. And so at some point that has gone beyond a situation where they can kind of regain their lives.

SMOLLER

11:49:31
There are now treatments that are effective for this but it's an area where we are again seeing a growing number of people suffering from this in part because of the wars that we've seen, traumatic brain injuries that have -- that we increasingly recognize. So I think there is something real about that that really needs our attention.

REHM

11:49:51
So what is it that you hope to accomplish? What do you hope to see changed by writing this book?

SMOLLER

11:50:01
Well, you know, this book really emerged from my experience in two overlapping worlds, one of them as a psychiatrist, trying to help people who come in in tremendous distress with psychiatric disorders and the other as a scientist trying to understand the role that genes and experience play in these disorders. And in both situations the same questions kept coming up, how do we end up with the mental lives that we do? What are these disorders about? How do they emerge and so on?

SMOLLER

11:50:26
And my hope is in writing this book and in the work that we're doing, for us to sort of take a step back and start to begin to understand these things with a map of how the brain and the mind work. Because I think that not only helps us understand what makes us tick but also how we can make sense of these disorders when it is important to treat something. What kinds of new treatments we can develop.

SMOLLER

11:50:54
And this is -- I'm not alone in this and as I mentioned, there are a number of scientists now moving in this direction. But I think it puts us on more firm ground and less controversy in some ways about some of the diagnoses we have and gives us insights that will let us both de-stigmatize, demystify these disorders and be in a much better position to treat them.

REHM

11:51:17
We have an email from Kathy who wants to know how much influence the medical insurance industry has in editing the DSM. Insurance companies require diagnosis reference numbers for reimbursement.

SMOLLER

11:51:38
It is true that one of the ways that the DSM has become such a major force in our lives is that it is used as the manual on which a lot of decisions are made, one of them being insurance reimbursement. That's not to say that the insurance company is dictating these diagnoses but this is a manual that, you know, psychiatrists learn in training to use. It's used by pharmaceutical companies to develop indications for treating things and so on.

REHM

11:52:07
But is there input on their part as well?

SMOLLER

11:52:12
Again, I'm not part of that process itself so I couldn't give you a very informed answer. To my knowledge that's not the case.

REHM

11:52:19
That's not the case. All right. And let's go to Burlington, Vt. Good morning, Megan.

MEGAN

11:52:29
Hi, how are you?

REHM

11:52:30
Good, thanks.

MEGAN

11:52:31
I was interested in something that you were talking about at the beginning of the program about how over 50 percent of Americans experience a mental disorder. But I was wondering how it compares to members from other cultures. I feel like Americans do have a tendency to over diagnose. Do other cultures have the same numbers?

SMOLLER

11:52:52
That's a really interesting question and actually there are some data on that. So that number of over 50 percent comes from one of the largest American studies. There have been surveys of countries around the world and the answer is that it differs depending on which condition you're talking about. So there're certain conditions that are more common in the United States than elsewhere. There are others that seem to have a pretty common prevalence around the world. Schizophrenia, for example, affects about half a percent to one percent of people in a variety of cultures that have been studied.

SMOLLER

11:53:21
Some of the anxiety disorders do seem to be more common in the United States than in Asia for example. Eating disorders seem to be more common in the West than in some other cultures. And some of that may have to do with the way people report to stress and interpret their symptoms and what they describe. But some of it may be real cultural differences in what people experience.

REHM

11:53:42
And you're listening to "The Diane Rehm Show." Let's go to Providence, R.I. Good morning, Lola.

LOLA

11:53:53
Good morning, Diane. Thank you so much for taking my call.

REHM

11:53:55
Sure.

LOLA

11:53:56
I love this topic. It's very interesting. I had a question about the role of Eastern philosophy like meditation and relaxation and how that could impact psychiatry and maybe possibly reduce the number of people who are diagnosed with these anxiety disorders. Because it seems as though a lot of this has to do with the fact that Americans are rushed and always -- you know, rushing to do things and not relaxed enough. Can meditation play a role in psychiatry and has the Psychiatry Association looked at the benefits of meditation?

SMOLLER

11:54:35
Well, that's an interesting area because there actually are a number of studies now that are looking at the effect of meditation, not only on symptoms but even on the brain. And there's some limited evidence that mindfulness and meditation has been associated with changes in brain structure that correlate with improvements in people's levels of stress and so on. And this is pretty early stuff.

SMOLLER

11:54:58
But I think people do recognize that there are many ways to alleviate anxiety. And many of them don't involve formal psychotherapy or even medication. And exercise is another one actually...

REHM

11:55:10
Exactly.

SMOLLER

11:55:10
...which has been shown not only to be helpful for anxiety and depression and, you know, I'm not sure that -- with severe depression, that's not going to be enough typically. But we now understand something about how exercise exerts that effect. It actually also has effects that promote the health of certain brain areas involved in how we regulate our emotions.

REHM

11:55:34
I think the understanding of the brain is just in its infancy. It's really fascinating to hear all the new work coming out. Here's a very quick but interesting email from Laurie who says, "Experience has taught me that being different from others is unacceptable, but not abnormal. I am a woman who grows a beard. The women in my family all have had this on both sides of the family, so who's to say it's not normal."

SMOLLER

11:56:16
Well, that's an interesting question as well. I think that one of the things that I suggest in the book again is that there really is a vast spectrum of normal that is sort of human possibility. And each of us plays out a different trajectory -- I'm talking about when it comes to behavior for example -- that has to do with the variations in our genes, the variations in our experience which can have effects on how we interpret the world and even how our genes get expressed, and to some degree chance.

SMOLLER

11:56:48
So there are many factors that create this broad tapestry of normal. And when it comes to abnormal I think you're right, that some things that we consider abnormal are really just unacceptable from some people's point of view.

REHM

11:57:03
Jordan Smoller. His new book is titled "The Other Side of Normal." Jordan Smoller is associate professor of psychiatry at the Harvard Medical School. Thank you so much.

SMOLLER

11:57:19
Thank you, Diane.

REHM

11:57:20
And thanks for listening all. I'm Diane Rehm.
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