I keep coming back to this issue, even though I don't really have a horse in this race, as I do not accept third party payment and am thus rarely called upon to assign a DSM IV diagnosis. But it is one of the major problems in the field and it has great impact on how people view their problems and how best to tackle them. So I keep gnawing away at it.
Today, Furious Season's Phillip Dawdy has another good piece on this problem from the bi-polar angle. I urge you to read it. And to read as well this article on Paul Minot's blog, Candid Psychiatrist -- I should try to contact him as he in in Maine and not that far from me. Dawdy quotes Minot from elsewhere:
"Bipolar disorder isn't actually a disease.
It's a collection of signs and symptoms lumped together in a diagnostic classification that has no basis or assumption of causation. There is no known neurochemical abnormality associated with "bipolar disorder", and patients with this diagnosis certainly have a plethora of different problems, all lumped together in one convenient/dumb diagnostic classification."
I would expand that to include depression and most of what any of us see in our practices. The problem is as usual a complex one. There are economic forces at work with pressure from the insurance companies to develop easily regulated treatment protocols, from patients who want their treatment paid for with their insurance, from psychiatrists who have their own issues of identity within medicine, from drug companies wanting customers for their products. And there is precious little space anywhere for reflective consideration of the process and what it means.
I wrote here about the problem of what constitutes remission and the permanence of any psychiatric diagnosis. What does it mean to tag a child with a diagnosis indicating mental illness, a tag that will follow that child throughout his or her life. One of the vignettes in the Frontline episode, "the Medicated Child" struck me -- the young girl who has been identified as bi-polar for years now can only think of herself and her moods, the normal moods of adolescence, first in terms of her "illness", which has become a primary part of her self identification. Who might she be, might she become if she didn't think so quickly of herself that way?
When I was working in community mental health, we worried about the stigma of mental illness, of what neighbors would think of the people we saw who came for help with their family issues. But we didn't think about what it means, the personal stigma, any of them might attach to themselves and that I suspect is a far more pernicious consequence of labeling. We want to imagine that we have waved away stigma by identifying problems as "diseases" thereby making them medical issues rather than moral failures or weaknesses. But what does it mean to identify oneself as a disease, e.g. "I am bi-polar"?
All of the economic issues are valid and important and must be wrestled with. But there is something deeper and perhaps of more consequence here and that is how we think about ourselves and what it means that we are so willing to embrace this notion of "I am my illness" as an identity. Minot, in another of his pieces, talks about demoralization. What happens to the sense of self when one becomes a disease? Does that not make the person no longer someone who can act herself to change her life, but rather one who must rely on expert assistance to get by? How do we help people become more effective and personally empowered by operating this way? Or is it the point to make us powerless and passive that we might be better consumers?