Map of life expectancy at birth from Global Education Project.

Monday, June 03, 2013

More on psychiatric diagnosis

Now that we've laid out some foundational issues, this seems a good time to go back to the DSM and finish constructing our deconstruction. Various categories of psychiatric diagnosis present quite different sets of issues. My friend Gary, in The Book of Woe, raises most of them in one way or another but he doesn't march us through them systematically -- it's not that kind of book. I'm a more boring sort of writer, however, so I'll just put the ducks in a row and knock them down.

There are indeed various things that can go wrong with our brains which have all the right stuff to be called a specific disease, and treated like one (to the extent treatment is possible). These would include Alzheimer's, Parkinson's, stroke, brain tumors, traumatic brain injuries, encephalitis of whatever cause. Here, we can find some gross abnormality in the perceptible physical appearance of the brain, and we can link these consistently and explicably to symptoms which are clearly undesirable and out of the ordinary. The bad news for the APA is that none of these are really psychiatric disorders. Neurologists, oncologists, surgeons, infectious disease specialists get the fees.

Then there's addiction, which seems to have a lot of the right stuff. A fairly well accepted theory of addiction to many commonly indicted chemicals is that they essentially hijack a specific circuitry in the brain that controls motivation, mediated by the neurotransmitter dopamine. There isn't exactly a lab test for this but the receptors involved are known. Effective chemical treatments are coming along for alcoholism and we also have designer opioids that can be titrated to satisfy craving without producing sedation or euphoria. (Other drugs which are sometimes abused or can produce dependency work in other ways, but again there is basic understanding of their mechanisms.)

The real debate here is whether the "disease" concept is the most practically useful, or perhaps morally appropriate, way to think about addiction. People who invite harm or risk by their ingestion of psychoactive chemicals have very different patterns of consumption, from a little bit all the time to occasional major binges; and as many people argue, it isn't the bad chemicals that produce addiction, it's usually other problems people have such as not having something else they want to do badly enough to motivate being sober. In this view, addiction isn't really an essential disease but rather a symptom of not having a life, as it were. More controversial, from the point of view of the neuroscience, the etiology, and the ontology, are proposed non-chemical addictions such as gambling, food, shopping and sex. If you accept that these can also be addictions, then the disease label seems even more problematic. The diagnosis is even fuzzier, especially since total abstinence from some of these activities is itself either abnormal or fatal; and the question of morality and personal responsibility becomes more vexed for many.

I don't have a right answer here. If the disease concept works for you in these instances, use it. If  you'd rather think of it another way, that's also defensible.

Then we have your so-called "major" mental "disorders," which are more or less schizophrenia and what is now becoming a penumbra of variously named psychotic conditions; bipolar disorder; and major depression. That these seem to have mutual inter-heritability suggests some (completely unknown) common etiological core, which helps make the case for disease. Schizophrenia has a classic presentation with onset in late adolescence or early adulthood; and a complex of symptoms including hallucinations, disordered speech and thinking, delusions, and deficits in social interaction.  There are drugs that can calm down the hallucinations and delusions, although they do leave people with flat affect and apathy, and can have terrible physical side effects.  (The drugs don't tell us anything about the cause of schizophrenia however. By analogy, the pain of a broken leg is not caused by morphine deficiency.)

All this argues for the ontological status of schizophrenia as a disease. It seems to be a reasonably identifiable specific thing, and you definitely don't want it. It turns out, however -- and this came as news to me -- that the diagnostic reliability of schizophrenia is not nearly what you might think. Many people don't exactly have all the symptoms. Ted Kakzcynski, for example (the Unabomber) was given a diagnosis of schizophrenia, but he does not have disordered speech -- on the contrary, he's pretty good with words -- and he doesn't hallucinate. Arguing that he is delusional gets you onto very thin ice -- he has opinions which are unconventional and subversive, but so do I. He doesn't think they're being beamed into his brain from Aldebaran. That he has the same "disease" as Jared Loughner is highly questionable.

In fact people's diagnoses can cycle among the major mental disorders and their sub-types, and diagnosticians will come up with different answers for the same person. One strongly suspects that there is some sort of common etiological core here, and in any case that some day we may have a specific physical  marker that corresponds to these presentations, or perhaps markers that can differentiate among them. The drugs we have for these entities, be they legitimate diseases or not, you would rather not take unless the alternative is even worse, which it often is. So the disease frame seems pretty defensible, but the attempt at sub-classification and naming, at the current state of knowledge, not so much. The basic problem here, then, is ignorance.

Next I'll go on to depression and other affective disorders; behavioral diagnoses; and personality disorders.

1 comment:

kathy a. said...

we're right now struggling with a relative who was diagnosed ~2007-8 (age 49) with early onset dementia. more recently, she finally got a better workup at a Big U Teaching Hospital, and they think it is a form of fronto-temporal dementia. this neurological thing is devastating and definitely on a downward course.

it's all really complicated, though. her mother was diagnosed with bipolar and had several hospitalizations (increasing the risk of dysfuction); her own behavior long before the dementia suggested some kind of mood disorder -- but she would never permit that kind of psychiatric assessment. the mood symptoms have become blazingly obvious (kinda like she was before, but the neuro decline leaves her very disinhibited).

in case you were wondering, severe dementia is not improved by mood symptoms. over the last several years, she systematically lost custody and unsupervised contact with her child, lost her job, had several unhappy police situations and criminal charges, lost her license, burned through savings and her disability/retirement income, had her house foreclosed, etc. in the past 3 months, she had to be moved from the foreclosed house, had 2 involuntary psychiatric admissions, got into such a manic state that she wasn't sleeping and ranted about injustices 24/7, demanded repeatedly to be taken back to the foreclosed home, attacked several people, accused everyone around her plus her elderly mother of grievous crimes against her, left the care home several times, etc. in happier moments, she told everyone she was going to re-marry her first ex-husband (he "showed her a ring!" - not), but when he told her they were just friends, she accused him of rape. and etc.

really, i could go on for pages. her behavior and what it has wrought, it is all exhausting. we know it is because her brain is broken. i've done everything in my power to get all the doctors as much info as possible, and the strong neuro diagnosis has meant that even her psych admissions were handled with great care, on medical wards. she's now safely in a locked dementia unit at a skilled nursing facility, where they are working on meds that will settle her the hell down without making her a complete zombie.

because she is so young to have dementia of this severity, she fits in absolutely nowhere. the acting out -- well, she can't function with people more her age, either. a less structured setting only invites disaster on the heels of disaster.

i'm sure you are correct that the major psychiatric disorders are probably clusters of disorders, and we just do not know enough yet because you can't just see them on a scan. but boy, howdy. there is something more going on with this relative than the dementia.