Posted by Dr. Vollmer on July 24, 2015
Pathologizing mood states is a justified criticism of modern psychiatry. Bipolar II is a good example. This is a diagnosis which implies that the person has pathological mood swings which vary from hypomania (which could be a desirable mood state) to mild or more severe depressive states. The treatment is a mood stabilizer, such as Lamictal, which often helps because Lamictal is an anti-seizure medication, and as such, it quiets brain activity. Once again we are in a place where the benefit of a medication does not, or should not, give rise to a diagnosis. In this case, the Lamictal helps with symptom relief, but that does not mean that the person is mentally ill. It would be the same as saying that if I take tylenol for my headache, and my headache subsides, then I have a “headache disorder”. Symptoms can be transitory, and hence, not speak to a prognosis or long-term course of the illness. Mood swings can be frequent or infrequent, like headaches, without casting a shadow of a mental illness on the patient. By contrast to Bipolar I, where the disease has serious implications for biological family members, and the course of illness is known, Bipolar II gives us no information about either genetics or the future course. We have returned to this line in the sand where there is a great controversy over when a patient has symptoms, but no diagnosis, as opposed to a diagnosis. The majority of my patients have symptoms, but do not meet criteria for a diagnosis. As such, I advocate for a deeper honesty about our tool box. We treat symptoms, and we do that well. Diagnoses, on the other hand, we need to improve.
“What makes her Bipolar II?” I ask my student as he presents a case. She gets irritable and she sleeps poorly. “Maybe she is going through a rough patch and she is unsettled,” I respond. “Maybe she has her panties in a knot:,” my new favorite expression. “Yes, yes,” my student agrees, as we both acknowledge that there is the language of training programs which forces diagnoses on people, and there is a language in the outpatient setting, which sees patients on a spectrum of coping skills. Students learn to be bilingual, in this way. Mostly, my students take this disagreement in stride. I, on the other hand, feel rage. I am deeply concerned about what these labels mean to patients. How do patients cope with getting a diagnosis, which might only apply to this particular period in their lives, and yet the diagnosis implies a long-term course? How do family members see their loved ones, when they carry a diagnosis of a “mental illness?” By labeling these patients Bipolar II, we strip them of the embracing the common human experience of stress, internal discomfort, and dis-ease. We teach them that the answer to their problems is embracing the sick role, rather than empowering them to learn to cope. Sure, coping skills are part of the treatment of Bipolar II, but it is different if there is a psychiatric label, as opposed to normalizing it as the stress of maturation, and coping in a world filled with uncertainties and pain. Once again, I conclude, Psychiatry has lost its way. Medications can help, but diagnoses for non-psychotic illnesses, at least most of them, do not.