"So, am I depressed, or Bipolar, or what?
When you have to diagnose a client with lots of depressive symptoms and a few, brief manic symptoms, you can be faced with a zebra riddle: is this a mild case of bipolar disorder? Or just a depressed person who gets very, very energetic when their mood improves ?
James Phelps, MD posts to the Psychiatric Times to suggest the problem may lay in the categories themselves. In a review of studies done with different definitions of hypomania (symptoms lasting at least four days… or three… or possibly two…) Phelps found hypomanic symptoms occur at lower and lower frequencies until they vanish altogether. He suggests Bipolar Disorder isn’t a ‘thing’, like a broken arm. Rather, he proposes it is a range along a spectrum of symptom intensity, the way doctors diagnose hypertension when their patient’s blood pressure gets up around 140/90.
What to do? Dump the existing diagnoses? Start over by rating symptoms and personality traits on empirically-based scales? It’s true that a switch to research-based constructs would bring us all closer to the reality we can know and measure. The downside is that it would produce chaos during the conversion. To know one’s diagnosis is a fundamental client right – how long would it take to explain diagnoses like, “5-2-6-2-1-7-8”? How would we file and reference the research on extinct disorders? Where will Borderline Personality Disorder support groups meet if we declare there’s no such thing? To overturn established systems, one has to counter massive inertia. American therapists of a certain age will remember how the U.S. didn’t convert to the metric system in the 1970s – and it had a 200-year track record.
Phelps suggests we contain the collateral damage by taking a cue from physicists. They’ve understood for years that light sometimes acts like a particle and sometimes like a wave. They’ve conducted useful research (and kept their heads from exploding) by using the most appropriate model for the problem they face. This “complementarity” principle means we can be more empirical without bewildering clients. For research, we’d use the ‘wave’ model, where it’s understood that ‘major depression’ and ‘bipolar’ mark points on a curve measuring the length and intensity of manic symptoms. When talking to clients, we’d use the ‘particle’ model, where we’d speak as though those conditions were as different as asthma and a hangnail. Would we lose specificity? Not enough to leave our clients uninformed. After all, even if Bipolar Disorder isn’t a ‘thing’, it shouldn’t take a psychology degree to get treatment.
@ 2012 Jonathan Miller All Rights Reserved
Salon.com ran an interview with Stephen Joseph, professor of psychology, health and social care at the University of Nottingham,U.K., and author of, “What Doesn’t Kill Us: The New Psychology of Posttraumatic Growth”. The headline? “How PTSD took over America”. The subtitle? “The diagnosis is now being applied to everything from muggings to childbirth. An expert explains why it’s bad news.” Interviewer Alice Karekesi asks questions like, “Do you believe that PTSD is over-diagnosed?”, “Is the emotional pain overblown in such cases?” and “Are there some cultures that are more prone to post-traumatic growth?” One quick scan and I was ready to ask Dr. Joseph blistering questions such as, “How long does a client need to suffer before they can skip the ‘growth’ and actually get some help?”
Until I re-read his answers. And noticed that Salon and Joseph were talking about different things. Joseph doesn’t claim post-traumatic stress disorder is over-diagnosed. He explains the definition of PTSD has expanded, but doesn’t argue that’s a bad thing. He notes some say the DSM over-medicalizes the human experience, but doesn’t take a stand on whether it does or not. The only “bad news” he explains in the interview? People who have a normal reaction to an upsetting event may believe they have PTSD.
I’ll be reading Joseph’s book in the near future. Blurbs for the book suggest it’s not about diagnosis, but the way one can grow during recovery from trauma, and emerge stronger and healthier than before. If there are meaty chapters claiming that PTSD is over-diagnosed, you’ll read the full update here.
Political observers note media coverage is often driven by pre-established narratives – storylines and stereotypes that journalists (overworked, underpaid, overstressed and under-respected, by definition) fall into. Why did Candidate X get labeled as a flip-flopper when Candidate Y changed positions, too? Because it fit a storyline, including people’s perceptions of X’s character. The narrative here seems to be that if you say you have PTSD (or any other DSM diagnosis), it’s more likely you’ve inflated mild symptoms into a mental disorder because you’re weak.
DSM-V comes out next year. Watch for more of this narrative as May, 2013 approaches.
@ 2012 Jonathan Miller All Rights Reserved
It’s a too-common newbie mistake: a therapist fresh out of grad school assesses a client who reports mild anxiety and maybe a little depression. Do they hear voices? Sure… every now and again. The poor client winds up misdiagnosed with Psychotic Disorder NOS, because the rookie assessor didn’t ask a crucial follow-up question: “When do you hear these voices?”
Hypnagogic hallucinations are visual, auditory, or tactile hallucinations that occur while drifting off to sleep. The term ‘hypnagogia’ is taken from the Greek for “inducing sleep”, and was coined by Napoleon III’s librarian, Louis Ferdinand Alfred Maury. Bódizs, Sverteczki, et al [i] suggested that elements of REM sleep continue in the hypnagogic space between full wakefulness and true sleep. If they’re right (and follow-up EEG studies [ii] support the hypothesis), it would seem our dreams can briefly blend with our waking awareness, like a computer-generated movie monster matted in with the actors. Psychic researcher Frederic Myers noted something similar can happen when we wake, and termed this a hypnopompic state. The DSM says this part of the normal human experience, like the illusion of hearing someone call your name. I won’t count any reports of hallucinations in bed as a sign of mental illness, even if the client insists they were wide awake at the time.
Necessary follow-up questions can fall victim to time pressures. In community mental health, the pressure can come from management less concerned about about precise diagnosis than they are about meeting Medicaid timelines . In private practice, the pressure can come from clients impatient to move past formalities and start fixing their problems. A client’s eligibility to adopt a child or buy life insurance can hang on the question of, “Have you ever been diagnosed with…?” Misdiagnoses based on something as ordinary as hypnagogia can affect them long after their actual mental health problems are resolved.
How ordinary are hypnagogic hallucinations? Muppets have them:
Key lines come at the start of the third verse:
“Have you been half asleep, and have you heard voices?
I’ve heard them calling my name.”
@ 2011 Jonathan Miller All Rights Reserved