So how much of a freak am I anyway? There is no question that there are tendencies I have which cause me problems from time to time. Of course I am not alone. We all have fears and worries, we all get down from time to time – sometimes quite seriously. Don’t we almost all have trouble concentrating? Don’t we all have bad habits that cause us grief? Do these issues make us mentally ill?
There was a great editorial a while back in the Los Angeles Times written by Allen Frances MD. In his article, Dr. Frances bemoans the tendency to medicalize relatively normal tendencies. While some of these tendencies may cause problems for people, is it necessary to call them psychiatric illnesses?
The Montreal Gazette also ran an excellent series of articles on the issue written by Sharon Kirkey.
Disease classification serves three main purposes. First, it facilitates communication. If I were to tell you I had agoraphobia, for example, you would have a pretty good idea of how my life is affected. Second, it facilitates research. If we all agree on the definition of agoraphobia, we can conduct research into treatments that work for each category. Finally, if specific treatments exist for each specific illness, then diagnosis becomes an important consideration in treatment planning.
The problem with psychiatric diagnoses is that very few of them have any clear and reliably observable patterns – and almost none of them have measurable physical markers. The result is a classification system based largely on clinical judgments. Clinical judgment may sound nice but it is notoriously unreliable. The sad reality is that a typical psychiatric dossier has almost as many different diagnoses as doctors who saw the patient. You would never see this in any other medical specialty. Someone with diabetes will have diabetes no matter how many doctors he or she sees. In addition, there is so much overlap in psychiatric diagnoses that almost every patient has one, or even several, “co-morbid” conditions. Not only that, but most conditions respond to the same types of treatments.
The reason for this problem with the classification of mental conditions is that people’s lives and personalities do not fit neatly into categories. There are times when our personalities may cause us problems – or cause them for others – but does this oblige us to find a name for every problem condition?
I do think we should look for patterns in people’s lives and we should continue to conduct research into techniques that help individuals overcome some of the more maladaptive ones. However, I do not believe that most of these diagnoses are particularly relevant to day-to-day clinical practice.
The media are fascinated with classifications and statistics. We like to read quotes about how many of us suffer from a specific disorder and what type of treatment will be needed to overcome it. In reality, however, most diagnoses represent some sort of prototypic conditions – an artificially defined cluster of symptoms that are seen in certain individuals. They are not truly distinct conditions. I like to think of them as points in a cloud. If people were represented by a cloud of behavioural and experiential patterns, we could arbitrarily define some points in this cloud. The result would be that some of us may find ourselves close to a single point but most would be classified somewhere between two or more points.
Prototypes and averages are important to help us advance knowledge but not necessarily to categorize people. For example, if research showed that as family size increases, there is a concomitant increase in financial stressors, sibling rivalries, and conflicts, would it make any sense to use a cutoff and say that family sizes of 7 or more have particular psychological needs? Of course not. It would make far more sense simply to look at family size as a factor to consider? Larger families may have additional challenges facing them than small families. For some it may cause no distress, for others it may be a significant issue. The only thing to consider is one of how each family copes with this particular factor.
Similarly, psychological factors can lead to anxiety and unhappiness and may have to be dealt with. When a person is struggling with depressive feelings, I will do my best to help him or her. Does it really matter on which side of a subjective line clients find themselves on? I prefer to consider the person’s life as a whole and examine the factors that influence the upsetting feelings. Research into prototypes guides my treatment but I never really see any of these pure prototypes in my clinical practice.
Perhaps it may be time to leave diagnoses to researchers or to use them only when a clear biological disease exists (psychosis, bipolar disorder, autism, etc.). I think we are becoming a little too obsessed with the notion of categorizing the uncategorizable.
Here is My April 6th column:
My mother thinks I’m not normal
(Source: Ma mère pense que je ne suis pas normale. Journal Métro: April 6, 2010)
Am I normal? Well, according to my mother, my wife, my kids, and most of my friends, the answer would be, “Umm…No!”
Now that we’ve established that, does this mean I am mentally ill?
We often hear the statistic that 20 to 25 percent of us have or will have a mental illness at some point in our lives. How accurate is this number and how meaningful is it?
The problem with statistics regarding mental illnesses is that it makes about as much sense as asking how many of us will suffer from a physical illness at some point in our lives. If we were to include the common cold, 100% of us will suffer from a physical illness, plus of course the one that eventually kills us.
When do we decide that a psychological issue is actually a disease? If mental illnesses are to include broad definitions of what is and is not normal, we can all be classified at some point. How many of us have felt depressed enough to contemplate death at some point…or avoid airplanes or dentists…or have trouble focusing on our tasks…or have bad habits…or have trouble getting along with others? Depending on how far we are prepared to cast the net, the percentage of mentally ill people can be staggering.
A small percentage of mental illnesses are just like any other brain disease. These include schizophrenia, bipolar disorder, and autism, and are likely due to some clear abnormality in the brain. It makes sense to classify these conditions as diseases.
For the rest of us, mental illness categories are extreme cases of everyday experiences. Where we draw the line is purely arbitrary. We need to classify mental illnesses in order to facilitate research and develop treatments, but very few of us fit neatly into these categories.
It makes far more sense to simply talk about how psychological issues affect our lives. When depressive feelings, fears and worries, or interpersonal conflicts cause us to suffer, or affect how we function, then we may choose to seek treatment. This should be the only determining factor rather than whether or not we meet any specific criteria.
As for what my mother thinks, I agree I am nowhere near normal but I do not believe I am mentally ill. My oddness is simply not extreme enough to affect my functioning or to cause me any suffering.
How I make others suffer is a whole other matter.
Posted in Mental health.Posted on 03 May 2010