Treatment has two parts: diagnosis and treatment. What you are leads to what you should do. It sounds really simple, but it is not.
If you have bipolar disorder the odds are if you are typical is that it took you about 8 years of treatment to discover it. The answer to diagnosis is simple. IT DEPENDS. It depends on who you see, where you live, and when you get diagnosed. I have known cases on the other hand where people are diagnosed with bipolar disorder for 20 years and go see another provider and are told that they are not bipolar, that for 20 years they have been living on the basis of an erroneous belief. It is not a simple matter of the facts mean such and such. What the facts mean depends on who is doing the diagnosis.
Reading news about the development of the new DSM I cant help but wonder about all the controversies. It is not an argument about facts. It is an argument about interpretations of facts and it sounds like many interpretations that were once “scientific fact” have lost favor and are about to be tossed. I dont see the same arguments about heart disease.
One report in particular caught my eye. Someone is suggesting a new diagnosis called post traumatic resentment disorder. Best I could tell it sounds like people who are mad at life because things didnt happen the way they would like. It sounds to some degree like most of the people I know. I cant help but wonder if some psychiatrists who are on a crusade to say that every difficulty in life is a medical problem dont need to find a better way to spend their time.
Robert Whitaker, in his fantastic book, “Mad in America” talks about the history of schizophrenia. And the absolutely startling thing he points out is that the people in the early 1900′s whom the concept of schizophrenia was based on would not be called shizophrenic by 1940. And if you were weird or strange in any way during the Cold War the odds of you finding out you were schizophrenic went through the roof. And as Whitaker points out it also depends on where you live. There is a difference between European and American schizophrenia. In America you are far more likely to be diagnosed.
It doesnt sound so very scientific does it? To some degree it sounds like what people see depends on what they believe in and for the most part people continue to see what they are used to seeing. Maybe psychiatrists are people too.
This is no way means that the misery that people live with is any less. That is the most common mistake that people who get fired up about the “myth of mental illness” make. Just because our description is suspect or inadequate doesnt mean that there is nothing to describe.
But it does make an important point. Labels and descriptions are about usefulness, not about truth. Beware of people on either side who get caught up in “the truth.” Simply put labels that tell you that someone or something is “nothing but this or nothing but that…” are simply wrong and they usually involve confusing the thing we describe with the description we use. If bipolar or any other concept is worth keeping it is because it is useful in helping people to find a better life. Period.
So when you get a diagnosis or someone you know gets a diagnosis dont let yourself become paralyzed worrying about whether or not it is true. The key is whether or not it works.
August 15, 2009 at 5:55 pm |
After a suicide attempt I was taken in and disgnosed with Bipolar Disorder. I could handle this. However I was on epivale and always felt the same hence it was difficult to believe.
When I was pregnant a psychiatrist who saw me for five minutes twice a year with three questions “Do I think that people can hear me thinking?’-Well that was my question and my only constraint…he claimed I was schitzophrenic-this I couldn’t tollerate It filled me with fear and it was difficult to then not be permitted to keep my child.
August 15, 2009 at 11:31 pm |
Wow. I have something to say about your post, but then I read Shannon’s comment, and just have to speak to her: I hope you were not deprived of your child on the basis of that kind of questioning! What a terrible thing to lose your offspring. I feel so badly for you, and I hope you are finding what you need.
As for psychiatric diagnosis. Having had medical training, and even one-time aspirations to become a psychiatrist, I started out with faith in the DSM. The more time I spend as a patient, and reading blogs, and thinking about how I’m going to get to a better place, I see the fallacy in labeling people as mentally ill. (This obviously also touches on another of your other recent posts.) My latest thinking is that our brains are as different as our mugs. Maybe I even brought this up on your blog before. You can categorize faces: male, female, European, African, Asian, old, young, attractive, ugly. And you can separate facial expressions: happy, sad, angry, etc. But just saying someone (like me) is a male, of European descent, middle-aged and with a look of concentration at this moment does not mean that is all I am or will ever be. It is not enough information for you to recognize me on the street, or to know what would work to make me more comfortable with being alive.
Psychiatric diagnoses have that level of precision. Some people have fluctuating moods. Some are chronically sad. Some worry all the time about everything. Some hear voices and have ‘odd’ ideas. Each of these persons can be diagnosed with a DSM label, and so by that definition they are mentally ill.
It’s a bit like saying only a certain race or gender is capable of running things. Only a certain emotional make-up is healthy; deviate far from that norm and you have a disease. Maybe you should be locked up and sterilized. You certainly can’t be in a position of leadership or responsibility (is anyone else old enough to remember Thomas Eagleton?).
Like you say, what matters is what works. And what works is what makes life a more satisfying experience. Dulling emotional responses, or squelching internal voices may help accomplish that for some people. But not for all. Some would be happier to be left with their minds in their native condition. Some can get a lot more happiness out of life by accepting their quirky brains than they ever can by acquiescing to long-term psychiatric drugs.
As someone who once bought the mental disease model intellectually and emotionally, I am astounded to find myself about to write that I am not sure that mental illness is a valid construct. I took all my meds diligently for years (I was a very ‘compliant’ patient). But I still felt rotten. Now I feel better even though I am on a milder chemical cocktail (hopefully soon to be none at all). So was I really sick? Or just confused?
I spend time on the local psychiatric unit, counseling patients about their legal rights when they face involuntary confinement. Some of these people are quite out-of-control, and would have trouble being safe on the streets. I can’t say what the answer is in those cases. Maybe when things go that far there really is a sickness going on. But that does not mean that the person has a mind that can never be trusted again. That they now should carry a lifetime diagnosis of, say, bipolar I. That they will require drugs forever, and can never learn to live safely and well without medication. Maybe it is the all-too-frequent permanence of mental illness diagnoses that is their biggest problem.
We are all different. ‘Some of us are more different than others.’ The problem with the ‘illness’ label, or a DSM diagnosis, is that it automatically means there is something defective. Maybe all that is wrong is that our eyes are open. That we see and feel more pain, or are more in touch with imaginative influences in our minds. Or we are more conscientious and want everything to be just right. Or impulsive. Or scared. These are not illnesses, they are responses to life. Maybe they are exaggerated and do not serve us well. Maybe medications can help us live fuller lives. But I object to being told my brain is abnormal, and that the person who never soars into ecstasy or crashes into sadness is healthier and (by implication) better.
It cannot be overstated: what matters is what works. If having a diagnosis in hand makes one feel vindicated, so now they can show people they aren’t just lazy or selfishly pessimistic, then it is a good thing. If it helps select a medication to get someone balanced enough that they can go home and work on better solutions, then maybe a diagnosis is useful. The same if they lead a person to the most helpful shelf in the bookstore. But if it means I can never get long-term care insurance (I can’t), or be trusted to practice medicine (a psychiatry program I applied to reported me to the medical board), or that I will always need to take medications that wreck my body and undermine my self-image, then they are most definitely not OK. That kind of thing happens so often, that it is easy to understand why people with mental/emotional/behavioral/psychiatric illnesses/conditions/disorders/abnormalites/challenges/dysfunction/gifts object to the psychiatric model. When diagnostics work they help a little. But when they are overused, misinterpreted, or otherwise go awry, they do an incredible amount of harm.
August 16, 2009 at 11:15 am |
[...] That happened yesterday on Hopeworks, when I wrote a comment discussing two posts: ‘What diagnosis depends on‘, and ‘On the words we use‘. The subjects were diagnosis and semantics in mental [...]
August 19, 2009 at 9:53 pm |
[...] pieces written by Larry, the author of the Hopeworks Community blog. (One of his posts talked about diagnosis, and the other about semantics.) If one were to compile Larry’s work with my essay and the [...]