Thinking Outside the Diagnostic Box

John McManamy Health Guide
  • "Jane" had good news to report. The MRI scan said her brain was fine. The bad news is this means she has no idea why her brain is in a fog. Nothing has helped, she reports. "I want to live, laugh, learn, remember, have a future, be loved. Is there something the MRI didn't see?" she asks.

    Jane posted her question in the "Ask" feature here on BipolarConnect.

    Welcome to the world of psychiatry, Jane. Think of psychiatry as neurology's "too-hard basket."

    Neurology is about the obvious. If you have a cyst or a lesion in the brain, an MRI will pick it up and a neurologist can discuss your options, which may involve surgery or meds or doing nothing. We also tend to be talking about symptoms that are clearly identified with the brain in a clear state of physical breakdown or malfunction, such as dementia or epilepsy.

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    Psychiatry, on the other hand, is all about the subtle: dopamine not reaching its destination, neurons failing to boot up, a biochemical circuit-breaker somewhere overloading. These are things an MRI is not likely to pick up. In some ways, they are as invisible to us as germs were prior to the invention of the microscope.

    Plus we have this added twist - in psychiatry, we tend to be talking about symptoms associated with behavior. We know there is a biological component to behavior, but no one is ready to rewrite psychiatry based on the current state of brain science.

    That will change. In the future, as brain science is able to more definitely explain certain aspects of human behavior, the distinctions between psychiatry and neurology will blur. Let me give you an example concerning a recent brain science study I came across the other day:

    An article in the March 1 Biological Psychiatry reports that researchers at Yale, using electron microscopy, detected structural changes in the neurons of rats as they were induced into "depression" and in coming out of depression. Not only that, the researchers were able to interpret what these structural changes meant.

    Let's follow this through hypothetically: Suppose that at some future date these same researchers were able to identify the underlying causes to these structural changes, definitively link them to depression symptoms, and pick up the anomaly on some kind of brain scan or lab test.

    Suppose other researchers made parallel findings, say a signaling pathway short-circuit that resulted in depression symptoms. Then, instead of doctors talking about this type of depression or that type of depression and prescribing antidepressants, they could conceivably be diagnosing us with "neuronal structural changes disease" or "signaling pathway short-circuit disease" and prescribe meds that directly work on these biological targets.

    In many ways, the future is now, which offers hope for Jane. At the 2007 American Psychiatric Association annual meeting, I listened to Stephen Stahl MD, PhD of UCSD talk about mental illness in terms of breakdowns in various brain circuits. Various symptoms from seemingly unrelated mental illnesses tend to share these circuits, he said, which raises the whole relevance of a psychiatric diagnosis in the first place.


  • Dr Stahl confessed, with probably only slight hyperbole, to writing in a diagnosis "in order to get paid." Then, "I forget about it."

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    This translates into psychiatrists learning to think outside the diagnostic box and not being afraid to prescribe medicines "off-label," that is for uses not indicated by the FDA. Two decades from now, psychiatry - if they are still calling it that - is bound to look very different than it is now. We know that because of the changes taking place today.

Published On: March 22, 2009