Midweek Medicine: Diagnostic Jiggery-Pokery

I’ve previously expressed some of my disquiet about the diagnostic practice in psychiatry. I am really concerned that we are widening our notions of illness far too much, and beginning to include a lot of normal experience. How else can one interpret the statistic from the recent Australian National Mental Health Survey that proposed to inform us that 47% of the population will experience major depressive disorder during their lifetime?

Sick or Normal?

Sometimes life is hard. Sometimes people can be very distressed by it. That does not mean they are ill, or responding in a pathological way. Rather it means they’re human. While they might benefit from some sort of help, I am not convinced that a doctor – who deals with disease – is the best person to provide that help. I am not convinced that medication is a rational response to life’s vicissitudes (damn good word that: vicissitudes).

So what do I think should be a psychiatrist’s business? Schizophrenias/psychotic disorders certainly; bipolar disorders, melancholic and psychotic depressions; generalised anxiety is so close to major depressive disorder that it probably needs to be lumped in there as well; and OCD is probably best seen as a neuropsychiatric problem, so that’s us too.

See how thin DSM 5 could be? All they had to do was ask me to write it.

To be clear, I’m not saying everything else in our diagnostic lexicons is not in need of – and deserving of – help; I’m just saying that it might be wrong to see these states as illness, and therefore the proper business of medicine. For example: PTSD. Something terrible (outside normal human experience) happens to you, and you have nightmares, poor sleep, anxiety, avoidance of triggering situations and the rest of it. Are you sick? Are you disordered or ill or pathological? Of course not. So why are you sent to see a psychiatrist – a doctor who deals with mental illnesses? Your symptoms are (at the extreme end of, true) a normal human response. Not ill. Not sick. Not disordered. Just extreme. Yes you might well need some help (probably from family, friends and generally caring people, rather than well-meaning but interfering strangers intent on making you talk about it again and again and again and …), but I really don’t see why you should be seen as needing to see a psychiatrist.

Grey and greyer

Of course it’s not as clear as that. A good example is to be found in the mood disorders. I’m not even going to go into the difficulties inherent to any thought of subtyping depression in a way valid enough to allow differentiation of service and treatments offered. I’m going to talk about bipolar disorders, especially bipolar II, and a couple of areas of greying: cyclothymic disorder, and borderline personality disorder.

Borderline Personality

Borderline personality is a very interesting entity. It is in my opinion a useless diagnostic construct, and I’ll try to remember to do a future post discussing why I think that. In any case, there are many areas of symptomatic overlap with bipolar II: the impulsivity (which could be seen during hypomania); the affective instability (which could easily be seen during hypomania or mixed states … yes yes, mixed affective state means in DSM IV it’s bipolar I not II – don’t bother me now, I’m blogging…); the recurrent suicidal behaviour (which could accompany the depressions); chronic feelings of emptiness (likewise easily a manifestation of depression); and difficulties controlling anger (as in hypomania). Sure, there are the overall caveats about personality disorders being pervasive and persistent, rather than episodic, but that’s in fact not always easy to determine – especially since people with bipolar disorder don’t have the decency to have nice clean and clearly-defined episodes with complete remission in-between. These inconsiderate people actually spend over half their time symptomatic in one polarity or another (or mixed) according to a number of studies – for example two articles by Judd et al published in the Archives of General Psychiatry: ‘The Long-Term Natural History of the Weekly Symptomatic Status of Bipolar I Disorder‘, (June 2002) and ‘A Prospective Investigation of the Natural History of the Long-Term Weekly Symptomatic Status of Bipolar II Disorder‘ (March 2003). With so much of their lives affected by illness, it can be extremely hard to tease out “personality” from illness.

So if we see people with bipolar disorders we should probably see people with borderline personality disorders too (if we have to keep the diagnosis at all …)

Cyclothymic Disorder

Cyclothymia’s a funny one. To be honest I’d not tended to think about cyclothymia until recently, but in the last little while I’ve had a few patients who are kinda sorta but not really almost bipolar and that led me to think about it – and even look it up!

Anyway, how does DSM IV define cyclothymia? In a very messy fashion, I would say. The defining characteristic is milder mood disturbance than a bipolar disorder, but similarly both depressive, and (hypo)manic. You’re “allowed” to have actual hypomanic episodes, but not major depressive episodes; for some reason hypomanic episode plus major depressive episode is one disorder (bipolar II) and hypomanic episode plus subthreshold depressive symptoms is a different disorder (cyclothymic disorder).

But it gets worse. It’s only for the first 2 years (ah! those magical 2 years!) that you’re not allowed depressive (or mixed) episodes; after that you can, but instead of revising your diagnosis, we’ll add another (billable in the USA, I presume) diagnosis to your stack, labelling you with bipolar (I or II) and cyclothymic disorder.

It’s ludicrous. Surely we’re simply looking at different stages, degrees, or manifestations of a bipolar disorder? I guess I’m a lumper, rather than a splitter; it just doesn’t make sense to me to come up with seemingly endless and apparently arbitrary categories, that blend into one another so much that we have to end up saying a person has a whole bunch of diagnoses – when it’s probably just one illness evolving over time and interacting with other aspects of the person’s past and current life.

I’m not sure I have a conclusion, or even a point, but I enjoyed the rambling.

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Tags: diagnosis, medicine, mental health, mental illness, psychiatry