65. Sleepwalking blindfold, into an amorphous tapestry.

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Historians agree that modern times began in 1980, with the invention of Pac-Man.

When did it all go wrong? The answer it seems is 1980. And, to a lesser extent, 1988.

Certainly, quite a few things went wrong in 1980. John Lennon was murdered, the Iran / Iraq war began, Robert Mugabe was installed and worst of all, the post-it note went on sale. In mental health, our particular Chernobyl was an explosion of toxic diagnostic heterogeneity. 1980 saw the invention of the concept ‘major depression’ (MDD). With the publication of the DSM3 diagnostic manual, most emotion-based illnesses was fed into a diagnostic Magimix. This turned out to be very convenient for certain people. One, (sloppy) people who don’t like making diagnoses. Two, the (wicked) inventors and propagators of so-called SSRI antidepressants. Rampant heterogeneity was very inconvenient for anyone who wanted to investigate the possible causes and treatments of Depression. Edward Shorter explains the story much better than I can.*

Certain discrete entities, that should have been studied much more carefully, got lost in the new, amorphous tapestry of MDD. One of these was the notion of ‘biological symptoms’ such as appetite and weight loss, early waking and diurnal mood variation (DMV). The classic ‘melancholic’ patient felt much worse early in the morning. Studies of cortisol and other hormone levels throughout the day showed a changed pattern in most depressed people. Of particular interest was the finding that most depressed patients failed to reduce their cortisol levels even when given a steroid tablet the night before. This led to the ‘dexamethasone suppression test’ and other early attempts to find a definitive lab test for Depression. Old school psychiatrists regarded DMV as a cardinal symptom of melancholia. They separated melancholia from other types of depression with barbed wire, landmines and a no-fly zone.

Today, research into circadian rhythms in organisms and the body clock in humans is a major strand of research in life science. Gene expression studies are the way forward.  And this week, even the BBC acknowledged this by holding a ‘Day of the Body Clock’.

Quite what the editors had in mind for the body clock day remains a mystery. Each news program had to slot in a body clock item but the presenters looked bewildered as to why. We heard that sportsmen performed better in the evenings. Some brave schools are shifting their timetable for teenagers later into the day, when they are more likely to be awake, although the teachers are more likely to be asleep. More interestingly, scientists told us that society was guilty of a ‘supreme arrogance’ in trying to over-ride our need to get enough sleep. Prof Russell Foster, at the University of Oxford, said people were getting between one and two hours less sleep a night than 60 years ago. We were warned that ‘Modern life and 24-hour society mean many people are now “living against” their body clocks with damaging consequences for health and wellbeing’. Further support then for the Blur Theory – Modern Life is Rubbish. Sleep, like lunch and the concept of Melancholia, was abolished in the eighties.

Studies continue to reveal that a sub-group of depressed patients show an abnormal expression of clock genes. Several promising types of non – drug therapy for depression were based on trying to adjust the body clock: Sleep Deprivation, Phase Advance and Bright Light therapy. Unlike SSRI antidpressants, these are treatments that cost hardly anything and can easily be implemented at home. Also unlike SSRIs, these are treatments that no-one ever tries. The post-it note and Robert Mugabe are here to stay, but Shorter is correct to say that MDD must go: ‘melancholia and non-melancholic depression are quite separate illnesses’. I’m having the bumper stickers printed now.

The idea that deliberately reducing sleep can act as an antidepressant seems counter-intuitive. But it’s possible that the insomnia in depression is the body’s attempt to defend itself against low mood. Which means that society as a whole may be trying to stave off existential despair by staying up late.

*Edward Shorter, 2014, The 25th anniversary of the launch of prozac gives pause for thought: where did we go wrong? BJPsych, 204, 331-2.

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5. Knowing what to call things

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An early classification system for depression, using cake.

Doctors and psychologists have invented a huge vocabulary of jargon. The downside of this enterprise is that non- experts are artificially excluded from participating. The upside is that at least we have a name for practically everything that might happen.

For instance – what do we call that thing – you know, in catatonic patients, where you pull their finger gently and you tell them to resist your pulling, but they follow your pull anyway without resistance, is there a word for that? How about mitgehen?

What about that thing where people mix up a coincidental event with a causal event? How about attribution error?

What’s that part of the wrist called at the base of the thumb? How about the anatomical snuff box?

How can we describe a loose pattern of findings that might include aspects of subjective history, observed behaviours and objective measurements, without necessarily implying a causal agent? How about a syndrome?

Depression has been described and categorised in so many different ways. We had reactive, endogenous, melancholia, major, minor, neurotic  and many more types. We have dysthymia and neurasthenia, we have bipolar 1 and 2. As stated by medical man, comedian and philosopher, Harry Hill, and an excellent catch phrase and running gag: ‘you’ve got to have a system’.

We are often accused of inventing diseases, for instance ‘medicalising’ ordinary human problems such as poor attention. More accurately though, we try and classify problems rather than invent them.

Classification is hugely important to doctors, partly because we have a geeky fondness for lists and tables, but mainly because all of medicine operates through a process of Pattern Recognition.

What we call each pattern doesn’t fundamentally matter, but it may matter a lot for social or political reasons. For instance if we diagnose ADHD or Asperger’s Syndrome, rather than identify a certain kind of character, that might mean extra funding and help at school for someone. Diagnosis could make the difference as to whether someone who offended got sent to jail or hospital.

These issues largely flow from the way society is organised and what part the medical community has come to play within the processes of maintaining social order, rather than whether the Pattern is a genuine entity.

There are lots of ways of describing Patterns of behaviour. If there is a recognisable Pattern then there are a few things we need to say about it. Take a simple example, no, lets take a really complicated example – Anorexia Nervosa.

Psychiatrists have defined this illness so that there are three necessary components -the person should have lost a lot of weight, stopped having menstrual periods (if they had them before), and have a certain set of views about their body size. Both the first two aspects are easy to measure, the third one not too difficult to find out if the person will speak to you.

Anorexia seems to be both a valid and reliable diagnosis. By valid, we mean there is a real problem that we can identify and measure, by reliable we mean that people would agree on whether someone suffered from Anorexia Nervosa.

But is there truly an illness called Anorexia Nervosa? Only perhaps in as far as that is what we agree to call a certain type of problem. Diagnoses in Psychiatry, for the most part, are conventions between us regarding what Patterns should be called.  Are there people we meet who seem to fit the criteria for Anorexia Nervosa? Yes.

Our health system, be it the NHS or private sector, will demand that we make a diagnosis. We have to use a system such as the International Classification of Disease or the Diagnostic and Statistical Manual. In the UK we tend to use the ICD10. That will give you a number code, such as F10, if you drink too much alcohol. The codes can be quite detailed if we use more digits, e.g. F10.4 if we drink too much alcohol, stop drinking for a day or two and get delirious. If we had an epileptic seizure during this we will get F10.41.

Are there people we meet who get Delirium Tremens some of whom have a seizure? Yes.

But why bother to label certain types of life problem and include them in a list of supposed Psychiatric conditions?’ I am not a number, I am a human being’, yelled Patrick McGoohan in The Prisoner. ‘Pigeon holing everyone’ – that is something Psychiatrists are accused of all the time, along with another favourite: ‘pumping people full of drugs’.

Ironically the interest in tightening up diagnosis in Psychiatry came as a result of a fascinating series of studies, the international pilot study of schizophrenia, or IPSS. The IPSS looked at the use of the term Schizophrenia in different countries including USA, USSR, UK, India and Nigeria.  This study seemed to find that a larger number of people were receiving the diagnosis of schizophrenia in certain countries (USA and USSR).  The American and Russian psychiatrists were calling a larger proportion of their patients schizophrenic.

At that time popular belief in the West was that the Soviets were falsely calling political dissidents mentally ill and locking them up in asylums. Whereas in the USA the disparity was put down to the way Psychiatrists traditionally understood the concept of schizophrenia.

It was soon recognized that it would be pretty difficult to do research into the causes or treatment of any disease if we could not even agree who suffered from it in the first place. Hence a huge amount of work sorting out a valid and reliable diagnostic system – DSM in the USA and ICD for the rest of world. The current versions – ICD10 and DSM4 are very similar in day to day use. So we can be reasonably sure that someone with Anorexia Nervosa in Milan has got a similar type of  problem to someone with Anorexia Nervosa in Birkenhead. So if we find Cause X or Therapy Y in one place, it might prove useful in any other place. Such is globalization.

Much  of the criticism of diagnosis in Psychiatry is based on what happens to people, and society, as a result of diagnosis happening. But criticizing diagnosis itself is as foolish as suggesting that it is impossible to classify colours of the rainbow or garden flowers.

The point is, sound diagnosis can be liberating as well as restrictive, it all depends on what we do with it. The danger is in poor quality diagnosis, or the misuse of diagnosis. These are the same dangers that occur with any tool, cordless curling tongs in particular.

How does this affect the depressed person in their kitchen?

Your subjective experience needs putting into words if you have to tell another person how you are feeling. You are free to create your own diagnostic scheme for Depression, but to be useful it needs to chime with someone else’s scheme.

In the case of Depression, even experts who normally know exactly what to call things, have failed to create much of a system. The ICD10 for instance gives up on classification much beyond the level of severity:  Mild/Moderate/Severe. Its unlikely that mass protest and civil disorder will break out in response to this categorisation.

There is only one thing worse than labelling people, as Oscar Wilde definitely didn’t say, and that’s not labelling people.

And there’s only one thing worse than pumping people full of drugs… (an inquiry was told).