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).