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Diagnosis of Mental Illness
One of the great advances of medicine in the 20th century was the ability to accurately diagnose patients. It is something we take for granted today. Indeed, when the story is about a misdiagnosis, it makes the news “I was told I had bug bite, now it is Stage IV Cancer!” The New York Post loves these. We know if we can get a correct diagnosis, there can often be the correct treatment, or at least, we know there is no good treatment but the knowledge itself confers power. This works great for many medical issues. It does not work as well for mental illness.
What we diagnose today as mental illnesses are really syndromes. A syndrome is defined as a group of symptoms that consistently occur together, or a condition characterized by a set of associated symptoms. That’s not really the same as swab culture and finding out you have a strep throat infection. The symptoms of strep throat together are the syndrome. The definitive diagnosis comes from the test. Now, doctors don’t need the test, because, let’s face it, the symptoms of strep throat are pretty similar between people, but we can be sure.
In a mental illness, there is no blood test. There is no brain scan. There is no looking at neurotransmitter levels. There are symptoms. Oh, brain scans can show “features associated with …” and we know that increasing serotonin tends to increase mood. In some people. For some depressions. Maybe. Of course, the level in serotonin varies from person to person, and one person can have lower levels than another and not be depressed. What we have is a cluster of symptoms as a starting point. These get redefined. When I started out 30 years ago, doctors talked about “Agitated Depression.” This was when someone had low mood, lack of interest in pleasure, and often hopelessness but did not have depression’s normal lack of energy. This is not called “Agitated Depression” any longer. Today that is “Bipolar Mixed State.” Same group of symptoms, different syndrome.
When it comes to treatment, there is a wide range of various medications and therapy techniques. We can start with our diagnosis and try various things to see what works. It is not a science. Why is it that one antidepressant works for every member of a family but one? No one can really say. We have some gene testing that can point to how a person will be expected to metabolize some medications, but that is hyped more than it is actually effective. Finding the right medication is an art of trial and error. Of course, with therapy, there are many evidence-based practices that have a variety of proven effects. None of which will matter if the fit between the therapist and the client is poor (which is its own post, I think). Sometimes finding that right fit is also a challenge. And sometimes, the secondary benefits from the mental illness are “too good” to give up. Even when some people are miserable, they can hang on to the devil that they know.
This leaves us in a situation that is oddly modern and ancient. Before modern medicine, there was little good way to diagnose illness, and even when they got it, well, the treatments often ranged from ineffective to deadly. We are better off than that in mental health these days, but remember, lobotomies were a “Best Practice” in the mid-20th Century. Medical providers and therapists work with their clients to find the right approach. The client ends up doing the heavy lifting. Working on one’s mental health is not a passive experience.
As a therapist, I take mental health diagnoses by another provider as a starting point. Yes, I have to diagnose to make third-party payers (insurance) happy (though not for self-pay clients). Yes, it can be useful to know “This client has Bipolar I.” It will guide the questions I ask them about the past and inform the education I give them. It will not, however, be how I see them. They are not “Bipolar,” they have a “Bipolar disorder” and my job is to help them both learn to manage that illness and all the other parts of their life that are not reduced to meaningless due to a diagnosis.
I hope this rather high-level view helps. If you have specific questions, please ask them, and I am happy to respond.
Image from Jumpstory to which I have an account.
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Patented?
Agreed. I’d refute it, but why bother? Nothing I am going to say will change her mind.
I agree, but in the nicest way. I like Carol. I just wanted to push back against this absurd batch of no-doubt well-intended stuff.
Wishful thinking at best. Harmful if believed by those in need, but it’s a free country. As such, nonsense can and must (there he goes!) be called nonsense. Even by friends.
I say nothing about the details because I know nothing. But I sure could believe that sleep deprivation is at least a causal factor in some mental illnesses.
I think it’s a circular relationship. People with some rough mental illness tend not to sleep too well and that exacerbates there mental illness.
Yes.
Lack of sleep for long enough will cause psychosis. But sleep will fix it.
That’s a form of foxhole madness. In WWI, our soldiers would be awake for days and weeks at a time, unable to sleep in the hellish environment. Eventually they would end up running across the battlefield naked or something. We called it foxhole madness, and our military started making an effort to cycle guys off the front for 24 hours at a time once a week or something, when possible.
Bryan is right – you can’t treat that with drugs. They just need sleep.
If you look at how a brain works, it really should not need sleep. But every animal on this planet needs sleep of some kind on some schedule. We don’t know why – it’s a mystery.
That’s obviously not the same thing as schizophrenia or other pathologies.
Is there any medical condition to which we are not more vulnerable when exhausted?
Gripping hand. Problematic sleep disorders probably share a cause / causes with other maladies.
The way I see it, when I see a person who is fat and stupid, I am more likely to support a genetic cause for both than for either in isolation. And by genetically fat, I mean genetically stupid, because obesity (unlike stupidity) is a voluntary malady.
There are a precious few thyroid conditions and so forth, but just like ADHD, just because there is such a problem does not mean that anything more than 5% of diagnoses are anything more than the minimax convenience solution for teacher, student, patient, and doctor alike.
Sleep is often the first thing to thing to get messed up and not getting enough hurts you.
In bipolar type II people actually use sleep deprivation as a beneficial tool.
I have never seen that. Sleep hygiene as in good sleep is critical for it
People with bipolar II — lets see if I can remember this, it’s been a while, and my use of the label is a couple decades old and may not be consistent with the DSM-V — anyway, it is (or was) a low level bipolar disorder comparable to Seasonal Affective Disorder (but with quite different presentation). It is largely inherited. They get manic when sleep deprived and sometimes deliberately induce this themselves. For example, they put off necessary work until just before it needs to be done. Then they go sleepless for days at a time putting themselves into a (usually) low manic state and concentrate on the task at hand, performing it well. Then they crash and sleep for hours or a couple of days. This behavior is broadly conducive to social and economic success and lasts throughout one’s lifetime.
As another example, this behavior was not unusual at elite universities, and before mid-terms or finals it was not uncommon to find students having relatively minor psychotic episodes that resulting in in-patient admission and that resolved spontaneously with a few days of monitoring, redirection and sleep.
I’ll have to respond to that in full of the morning.
Oh, by the way, the downside of this is living with a chronic low-level depression that is partially relieved by alcohol.
Partially? This is no time for half-measures!
Speaking of sleep, I just got one of those Eight Sleep chill beds. For the price of 15 psychotherapy sessions you can sleep somewhat better. lol
They don’t explicitly tell you this, but I think the advantage is, you can have heavier blankets on in the beginning, and then at the end when your body gets cooler, you have the right amount of blankets. I am also a believer in the weighted blanket theory and this helps.
So far, it doesn’t seem to me you can use it to save on air conditioning, but I’m not going to be able to test that very well until next year.
I bought the whole bed, but I think if I would do it over I would just buy whatever bed I want and then get a chill cover instead. The reason I did it this way is one of the reviewers said the bed worked slightly better, but I don’t think that outweighs picking the bed do you want.
FYI, I just bought their new and improved one, so bear that in mind when you look at reviews. I have no idea if it makes any difference. It’s probably a scam to beat inflation.
Actually, that is a good way to get into trouble with addiction.
Drinking to cope with anxiety or depression in an ongoing way is foolhardy.
On Bipolar II. What you are talking about is courting hypomania, a low level of mania which is the counterpart to a low level depression. Honestly, we have a society that rewards hypomania. People don’t need as much sleep, they have a lot of energy, feel good, feel creative, and can be very productive. They may also spend too much money, increase risk taking, and increase sexual activity. Hypomania is a reason for poor compliance on medications.
See, people like it. It is like using speed. If we could promise people with bi polar disorder hypomania all the time with meds, the compliance rate would be near 100%. The problem is, the brain cannot maintain that. It will crash. Courting hypomania is the number one reason I see for people to go off meds and then wind up depressed on the back end. And pi polar depression is more resistant to antidepressants than unipolar depression, sorry to say. If you have hypomania you are going to get depression.
I work in mental health at a state prison, which is now the de facto primary inpatient treatment provider for much of the mentally ill. We have a long list of inmates who would have lived at a state psychiatric institute in the old days and probably never have ended up in the correctional system. The longer I work in the field, the more apparent it is that there is never One Solution to the problem.
That is three deep points in three sentences. Bravo.
I have heard of using sleep deprivation to break a depressive episode, and that it can be effective. The psychiatrist I heard it from said it had fallen out of favor, for the reasons you state. My understanding, though, it that it can be used not just for bipolar II, but also for unipolar depression.
Yeah! It’s really great (I hear).