Psychiatric Diagnosis

Several months ago I wrote about the advantages of seeing psychiatric problems on a spectrum rather than independent categories. And that it is also essential to look at the whole person: there is currently a terrible tendency in medicine and in psychiatry to reduce people to the neurotransmitters in their brains, which is not just a very limiting way of seeing an individual, it’s just plain rude.

One of the reasons why it is essential to look at the whole person is that the agenda of a physician and of a person asking – or being sent – for help may be entirely different. A doctor may want the voices to go away, and for the person to stop being fearful about the things that the TV is saying to them. The person may want help with making sense of their experiences. If someone believes that they are feeling this way because they’ve been abandoned by God, you can pour medications into them until you are blue in the face: they will not help the core problem. Yes, of course you can re-balance their dopamine, serotonin, GABA and acetylcholine receptors. But if their core belief has to do with abandonment, your efforts are unlikely to be crowned with success.

These issues came up again when I had the privilege of speaking to a meeting of the National Alliance of the Mentally Ill in Natchez, Mississippi last week.

There were all the usual questions about advances in mental health, and on the chances for recovery. My answer to that one is always the same: the chances for recovery from any mental illness – including schizophrenia and bipolar disorder – are better than they have ever been. The largest single barrier is expectation. If doctors, psychologists and therapists assume that nothing can be done apart from controlling symptoms, then it is unlikely that people will get better. We all know what will happen if we start the day assuming that’s it’s going to be terrible.

I’d like to highlight two blogs – here and here – that were started by the same person after she had recovered from a psychotic episode. She contacted me after my earlier posts. She has an excellent website which she started after an exchange with two psychiatrists who said essentially the same thing:
“If the person can be cured, then it is NOT schizophrenia. Schizophrenia is a chronic mental illness that has no cure.”

This is not true: but rather than being an indictment of psychiatry, it’s an indictment of bad psychiatry. We have a great deal of evidence that the brain is a highly plastic organ, and that many of the typical changes seen even in unmedicated people with the illness can return toward a normal pattern. This shouldn’t be a surprise: it has been known for many years that at least a third of people who carried a diagnosis of schizophrenia recover completely. To say that the recovery indicates that the original diagnosis was wrong is an extraordinary piece of circular reasoning.

The statement also implies that the writer doesn’t see a difference between healing, treatment and cure, which for me are three different interactions.

There is also another point that I made in Natchez: psychiatric diagnoses are still descriptive and are therefore largely at the level of the rest of the medicine of 100 years ago, when a person might be diagnosed with “dropsy,” “anasarca” or “icterus.” Terms now rarely used because we understand the underlying pathology. In the same way terms like schizophrenia will eventually give way to descriptions based on the biological, psychological, social and spiritual issues going on in a person.

Because the diagnoses are descriptive, getting too worried about the precise one is unlikely to be helpful. I once had a family become very angry with me. Their son had seen many specialists, who had all offered different diagnoses. After many day’s observation and exhaustive investigations, the one that I came up with did not please them. Because I wanted to treat their son as a human being with a problem that had responded to an antipsychotic and therapy, but they wanted him to have a less intimidating diagnosis. I tried in vain to explain that these were all just descriptors, and the important thing was that he was getting better with our treatment.

The reason for making a diagnosis at all is so that we can communicate, that it may guide treatment and allow us to offer some advice about prognosis. If someone has a heart attack, it is usually not too difficult to diagnose it. The reason for the diagnosis is not so that we can write it on a form or so that we can label someone, but because it can help guide us.

I certainly don’t agree with every one of points made in the articles that he’s posted, but that’s just fine. Active debate is always better than ignoring each other. Or as Winston Churchill once said, “Jaw, jaw, is better than war, war.”

On the main points in these blogs, I think that we are in complete agreement:

1. Even without drugs it is possible to induce mania and psychosis in just about anyone: sleep deprivation, arousal and sensory overload will usually do it in a few days. If someone has a family history of psychiatric problems it will likely take half as long. If they have a personal history it might take a quarter as long.
2. Recovery should be the aim for anyone with a psychiatric problem.
3. Recovery is not necessarily the same as cure.
4. Not all people diagnosed with “psychiatric problems” have them: some are having genuine spiritual experiences: I’ve seen many people going through kundalini and other types of spiritual awakening who had been given psychiatric diagnoses. I used to get some raised eyebrows when I had a string of referrals from clergy and spiritual teachers that usually read something like, “I don’t know if this person is psychotic or possessed. Please could you see them and advise me.”
5. The quest for meaning and purpose is essential to our humanity. I have seen some of the most damaged of people with large traumatic holes in their brain trying to extract meaning and purpose from what had happened to them. Psychotic, manic, depressed and cognitively impaired, but still trying to work out the meaning for them personally.

The major psychiatric illnesses can be very hard to help: I regularly see everyone else’s problems when I travel: 45 countries and 47 states at last count. But it’s very unusual to find someone for whom we can do nothing.

But I never let clinicians give up: the people who come to us for help deserve better than that.

And for people who got through the process on their own, I congratulate you. But I beg you, please don’t suggest to everyone that they can do the same thing. Many need outside help that addresses all five dimensions of their being.