Psychiatric disability

disability

Since psychiatric disability is often invisible and unquantifiable, considering oneself psychiatrically disabled can take on many meanings.  Certainly there are those who assess their limitations, whether imposed by thought disorder, anxiety, or mood extremes, and accurately gauge themselves disabled.  It is a strength to accept reality for what it is, to live one's life accordingly, and to claim the assistance society offers.  However, self-labeled psychiatric disability is not always accurate.  Clinically depressed patients sometimes underestimate their abilities and call themselves disabled the same way they call themselves failures, or bad or stupid — as self-denigration.  Others who yearn for nurturing or attention use disability as way to obtain these from caregivers.  And there are those who feel entitled to special privileges and treatment, and make undue claims on others using disability as a tool.

When I see a clinically depressed patient who is temporarily unable to work, I fill out disability paperwork, usually the California SDI form.  Such forms always ask me to estimate when the patient will be able to resume working.  With proper treatment, most depressive episodes significantly improve in less than three months, so that is what I usually estimate.  I consider this a little on the generous side, as I want my patient to have the disability benefit he or she deserves.  However, unlike recovery from pneumonia or a broken leg, recovery from depression varies widely.  Some patients are back to baseline in less than a month, others take much longer than three.  I have long been fascinated by the dynamics of predicting recovery.  Depression, almost by definition, leads to pessimism.  For this reason, my three-month estimate often strikes the depressed patient as too soon — too soon to hope to be well, perhaps too soon for me to expect much improvement of them.  Yet part of helping someone overcome depression is to lend optimism and hope.  I'd rather err on the side of quick recovery than to pessimistically assume long-term disability.  Indeed, when I've sometimes overestimated the recovery time, and the patient feels well in three weeks instead of three months, I feel I've made the more serious error.

A small subset of patients I see are, for want of a better term, "professional patients."  It is their identity to be ill and disabled.  It is their defining characteristic, the first way they introduce themselves.  Saying it this way risks "blaming the victim," as these people did not choose to be sick.  They are not malingering (intentionally faking illness).  However, even unwanted illness can assume a purpose for itself.  Disability becomes a calling card to see a variety of doctors, to call the crisis line and talk, to try a shopping bag full of medications.  It becomes a ready answer to that very difficult question: Who am I?  Some patients remain psychiatrically disabled because it is a way to be in the world, the only way they find comfortable or familiar.  It can be challenging to explore the meaning of such disability in therapy.  Patients sometimes complain that I don't "believe" them, that I should take their disability on face value.  I prefer to help them find more options in life, as sometimes disability itself is a state of mind.

From the psychiatric perspective, there is a fine line between assertiveness and undue personal entitlement.  On the one hand, it is healthy and strong to assert one's needs, to make a place for oneself in the world.  On the other, diagnostic terms like "narcissism" apply to people who feel, without reason, they are so special they need not obey the same rules as everyone else.  As described in my last post, some claims to keep pets in "no pets" housing, or to bring them to work or shopping for "emotional support," seem to cross over this line.  Since narcissism is ego-syntonic (not seen as a problem by the patient himself), it is frequently difficult to address in psychotherapy, or to interest the patient in therapy at all.

I have given three examples of dynamics that may prolong self-rated psychiatric disability: depressive pessimism, dependency and identity needs, and narcissism.  I could equally and conversely write about denial and counter-dependency as factors that might prevent a truly disabled person from acknowledging it.  However, the legal entitlements granted on the basis of disability make the former a more interesting social conundrum.  On the one hand, our sense of charity calls for helping the distressed and disadvantaged.  On the other, we recoil at self-declared victimization as a means to special treatment.  When disability is subjective and difficult to quantify, as it is in many psychiatric conditions, society does not know whether to embrace or reject it.  A culture of innate entitlement only makes this approach-avoidance conflict more acute.

Is mental illness categorical or dimensional?

In my last post I discussed the politics of psychiatric nosology and the revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM).  While the machinations behind specific disorders are fascinating, it is easy to miss the forest for the trees.  The basic idea of dividing mental distress and disability into diagnostic categories is itself controversial.

The DSM takes the stance that there are discrete "bins" (disorders) that individual patients can be sorted into.  For over 25 years there has been discomfort in the professional community about this, particularly in the case of personality disorders (Axis II of the DSM).  One of the architects of Axis II, Theodore Millon, PhD, objected to purely categorical personality diagnosis.  His website says:

It is Millon's view that there are few pure variants of any personality prototype. Rather, most persons evidence a mixed picture, that is, a personality that tends to blend a major variant with one or more subsidiary or secondary variants.

Statistics on Axis II disorders seem to bear this out.  Many studies show great overlap between categories, and many patients fit into more than one.  Clinical experience concurs: The patients I see are rarely "classic" cases of anything; everyone is unique.  Even everyday life experience suggests that personality features exist on a continuum:  One person is a bit detail-oriented, another is mildly obsessive, and another has serious problems with obsessiveness.  Yet the current DSM-IV-TR only defines "obsessive-compulsive personality disorder" (and allows mention of "obsessive compulsive personality traits," but this doesn't count as a disorder).  No nuance, no matter-of-degree.  Why do we have such ham-handed tools to describe psychiatric problems?

One reason is that psychiatry is a branch of allopathic Western medicine.  Unlike, say, traditional Eastern healing, we think in terms of disease categories.  And this fits fairly well for the most severe Axis I psychiatric disorders, such as schizophrenia.  The German psychiatrist Emil Kraepelin founded contemporary scientific psychiatry in the late 1800s by distinguishing the pattern of symptoms in schizophrenia ("dementia praecox") from that in manic depression.  In the early-to-mid 20th century, Freudian theory deflected such categorization, but it re-emerged as the dominant paradigm since the publication of DSM-III in 1980.  The 1990s "Decade of the Brain" heralded intensive research efforts to understand mental disorders from a medical perspective.  Today the vast majority of published psychiatric research is biomedical in nature, facilitated by the DSM's categorical framework.

In contrast to the medical psychiatric tradition, psychology has long pursued dimensional features of personality using empirical data.  Perhaps best known is the Five Factor Model.  Such models capture the variability and nuance of personality, but do not make sharp normal-versus-abnormal distinctions.  Each person exhibits one factor to a certain degree, the next factor to another degree, and so forth.  The combinations are nearly infinite.

The good news is that organized psychiatry is waking up to the value of dimensional assessment.  Position papers (e.g., here, here, and here) have long argued for this with respect to Axis II.  As working groups now meet to plan DSM-V, dimensional adjuncts are being considered for all traditional categorical diagnoses.

Is mental illness categorical or dimensional?  The "real" answer, I suspect, is that some psychiatric disorders will eventually be understood to have biological origins.  Schizophrenia will likely go the way of general paresis (syphilis) and Alzheimer's Disease:  When the medical cause of a psychiatric condition is finally understood, it is no longer considered a psychiatric condition.  It becomes the province of neurology, infectious disease, or another branch of medicine.  Psychiatry is left with conditions that defy medical explanation.  This is why I feel that, ultimately, dimensional factors are an irreducible feature of psychiatry.  Whether understood using Freudian psychodynamics, learning theory, or another psychological paradigm, human emotions and behavior will always be more subtle and nuanced than a categorical nosology can describe.

Laws, Sausages, and Psychiatric Nosology

Laws are like sausages. It's better not to see them being made.

Otto von Bismarck

German Prussian politician (1815 - 1898)

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published periodically by the American Psychiatric Association (APA), aims to catalog all recognized mental disorders.  As the name implies, it is used both for clinical diagnosis and for various statistical (population) uses.  I previously posted how social judgments are inevitable in such a catalog; little wonder DSM has long served as a lightning rod for social debates over what is normal versus abnormal.

The fourth edition (DSM-IV) was published in 1994, followed by a minor "text revision" (DSM-IV-TR) in 2000.  Groups of psychiatrists are now drafting sections of DSM-V, due out in 2012.

It would be nice to imagine that the process of creating and updating DSM is scientific and unbiased.  However, like laws and sausages, psychiatric nosology (disease classification) is more palatable the less one notices how it is made.  As reported in today's New York Times, putative disorders such as compulsive shopping, sexual fetishes, and binge eating have their advocates and detractors.  Transgender people have a personal stake in whether "strong and persistent cross-gender identification" remains a mental disorder.  (Interestingly, the stigma of this diagnosis is offset by its utility in obtaining insurance coverage for gender-reassignment surgery and other treatment.)  This recalls debates over the inclusion of homosexuality as a mental disorder in earlier editions of DSM.  Homosexuality was dropped as a diagnosis in 1973. It was replaced by “sexual orientation disturbance” and then “ego-dystonic homosexuality” before those, too, were dropped in 1987.

Anyone who imagines that these debates are coolly scientific is dreaming.  As social norms change, our notions of mental illness change with them.  The long-term trend has been an expansion of DSM, both in terms of dividing syndromes more finely, and also widening the scope of behaviors considered disordered.  Stakeholders include the APA itself, sole publisher of the 800,000+ copies of this essential tome; pharmaceutical companies who stand to gain or lose fortunes based on whether a particular human deviance is treatable with medication; insurers who cover treatment for disorders but not non-disorders; patients who either have a mental illness or don't; and scientists trying to collect data and make sense of the whole thing.

It is good to bear in mind that some disorders in DSM-IV-TR, like "nicotine dependence," do not seem very much like mental disorders — and that one is bound to stay.  Meanwhile, other maladies of the human spirit, like living a life devoid of meaning or purpose, are not listed in the current DSM, and are not likely to appear anytime soon.  In my next post, I'll discuss one aspect of psychiatric nosology, categorical versus dimensional ratings, that may improve DSM-V.  However, the inclusion of messy social judgments in DSM is with us for the duration, obscured in the finished product by careful prose, numerical labels for disorders, and a little quantitative data.  Laws and sausages aren't bad either — if you don't think about them too much.

Schizophrenia among us

I met a young man recently in a setting having nothing to do with psychiatry or mental health. He politely introduced himself and tried to learn the names of the others around him. He seemed socially awkward but inoffensive, and after I left I didn't give the encounter much thought. However, I learned that soon thereafter he showed increasingly odd behavior. He talked to himself, breached social boundaries, and acted aggressively for no apparent reason. Others had to keep an eye on him, and eventually he was escorted peacefully off the premises. The possible causes of such behavior are myriad: brain injury, psychotropic drugs, medical illnesses such as delirium or thyroid disease, and many others. One possible cause is mental illness, specifically schizophrenia. Schizophrenia is surprisingly common, affecting over 1% of the total population. As with many other disorders, schizophrenia can be mild or severe. Only a small minority of sufferers are institutionalized; the great majority live in society with everyone else. The class of medications called neuroleptics (anti-psychotics) have helped to make this possible, although some people with mild schizophrenia can function without medication.

I do not know whether the young man I met has schizophrenia. It would be presumptuous of me to attempt to diagnose someone I met only briefly in a social setting. But our meeting did spark some thoughts about the symptoms and deficits of this disorder.

A major hallmark of schizophrenia is auditory hallucinations (voices). When people "talk to themselves," particularly if they do so without regard to others noticing, it may be in response to hallucinated voices. The voices can be ignored for a while if they are not too severe. At the other extreme, if insistent voices command the person to hurt himself or others, this is a very serious situation that usually requires hospitalization. Medications are often helpful in quieting auditory hallucinations.

(Thanks to cellphones, particularly those with wireless headsets, people seen "talking to themselves" could simply be on the phone.  More than once I've passed someone on the sidewalk and assumed one of these scenarios, only to realize seconds later it was the other.)

Delusions are also prevalent in schizophrenia, as well as in other disorders such as delusional disorder and manic psychosis. Medications help with delusions too, but not as quickly as with hallucinations.

There are also "negative symptoms" in schizophrenia which include lack of emotional expression and a decreased ability to initiate action or speech. These are more resistant to medication, although the "atypical" neuroleptics available for the past 15 years are of some benefit.

More subtle are the "thought process" changes in schizophrenia, and these are what came to my mind regarding the young man I met. Classically, schizophrenic thought is described as concrete. The ability to think abstractly, metaphorically, and symbolically is impaired. For example, in psychiatric evaluations patients are sometimes asked to interpret a proverb such as, "People in glass houses shouldn't throw stones." While most healthy individuals understand this is not literally about glass houses, many with schizophrenia will say something like, "because the glass will break." Likewise, people with schizophrenia often cannot understand jokes or indirect references in the speech of others.

It is a sad and isolated existence to be cut off from so much human interaction, unable to share in common emotional experience.  Much of the meaning and flavor of life is contained therein.  This is not to say that people with schizophrenia cannot lead productive and meaningful lives.  They can, but it's hard.  My "up close and personal" encounter with someone possibly suffering these challenges reminded me that compassion, not fear or disdain, is the most apt response to the tragedy of schizophrenia.

Social judgments in psychiatric diagnosis

Around the time I was finishing medical school I published a short essay on subjectivity in psychiatric assessment.  The American Psychiatric Association had released the third edition of its Diagnostic and Statistical Manual just a few years before.  When it came out in 1980, DSM-III was a revolutionary update:  It provided specific criteria for diagnosing disorders, not the narrative descriptions of the previous editions.  In my essay I pointed out that the new, precise-sounding criteria still included social judgments.  For example, "inappropriate affect" was a criterion for schizophrenia, even though inappropriateness is assessed in relation to a given situation, depends on cultural norms, and is a judgment call.  My point was not that we should avoid social judgments in psychiatric assessment, but that they are inevitable, whether expressed in narrative descriptions or in numbered lists of diagnostic criteria. Fast forward 20+ years.  The current (11/10/08) issue of The New Yorker features an article by John Seabrook called "Suffering Souls: The search for the roots of psychopathy." It presents an overview of "the condition of moral emptiness that affects between fifteen to twenty-five per cent of the North American prison population...."  Seabrook notes that psychopathy is not a diagnosis in the current DSM-IV; the more general antisocial personality disorder subsumes it.  Much of the article revolves around brain imaging studies using fMRI to discern which parts of the brain are over- or under-utilized in psychopaths versus normals.

Functional imaging like fMRI has grown huge in psychiatric and brain research, almost to the point of becoming a fad in some areas.  Everyone wants to know what parts of the brain "light up" in different disorders.  Psychopathy is no exception, and such studies may uncover crucial findings about the condition.  More interesting to me, though, is that psychopathy is defined almost wholly by social judgment.  It causes no distress in the person who has it, and generates virtually no clinical signs outside the social sphere.

Early in the article Seabrook says the psychopath's main defect is "a total lack of empathy and remorse."  That was the way I learned it, too.  Such a definition categorically separates psychopaths from normals in a manner that is non-situational, relatively free of cultural bias, and avoids nuanced judgment calls.  However, it is also the last we hear of it.  The rest of the article takes a dimensional, matter-of-degree approach.  First presented is the well-known Psychopathy Checklist, or PCL-R, developed by Canadian psychologist Robert Hare.  The PCL-R interviewer scores the subject on 20 items, including irresponsibility, parasitic life style, lack of empathy, and shallow emotions.  Most researchers agree that psychopathy is present above a certain threshold score.  While the PCL-R has good face validity, its use to assess psychopathy requires judgment calls, taking the situation and culture into account.  As mentioned above, this is inevitable in much of psychiatry; we just need to be careful about it.

The danger surfaces later in the article.  Seabrook is driving with Robert Hare, who sees another driver run a red light.  Hare remarks: "'Now, that man might be a psychopath.  That was psychopathic behavior certainly -- to put others in the intersection in danger in order to realize your own goals.'"  Seabrook observes that this kind of behavior is commonplace, and "can make it possible to see psychopaths everywhere or nowhere."

The pejorative association of psychopathy with serial murders and other horrible crimes underscores the liability of seeing disorders "everywhere or nowhere."  In the last 25 years the DSM list of official psychiatric disorders has mushroomed.  As disorders are codified -- and importantly, as medications are marketed for them -- more and more people receive diagnoses.  What was once shyness has become social anxiety disorder, treatable with SSRI antidepressants.  Poor concentration and an inability to sit still has become ADHD, treatable with stimulants.  Social-context judgments (and financial incentives) grease the wheels of "diagnosis creep."

Social judgments in psychiatric assessment are inevitable, but that does not mean we can be casual about them.  On the contrary, their very subjectivity argues for closer scrutiny and care, as the pitfalls resulting from bias and intellectual laziness are grave.  If every personality quirk is a disorder, then psychiatric diagnosis loses meaning.  Worse, the parameters of normality narrow.  Tolerance of difference retreats in step with "diagnosis creep."

Psychopathy, like schizophrenia, are useful concepts.  Let's keep them that way, despite the shifting sands of the social milieu.