Credit: Thinkstock If we have the misfortune to break a bone, its diagnosis and treatment is usually straightforward. We have tools that allow us to see the fracture and we know exactly what is required to fix it.
Psychiatric diagnoses are far more subjective. The tools for accurate measurement of many psychiatric symptoms simply don’t exist, so we rely on clinical observation and description.
Nick Craddock and Laurence Mynors-Wallis’ editorial in an issue of British Journal of Psychiatry in 2014 explains that one problem plaguing psychiatric diagnoses is that more than one diagnostic system is in use. Also, our understanding of the higher functions of the brain lags far behind other areas of medicine. Any discussion of mental health has to be considered against this backdrop.
Bipolar disorder is an example of a mood disorder involving two extremes of mood: depression and mania. People with the disorder experience its effects in different ways and with varied levels of severity. The most common forms are referred to as bipolar I and bipolar II disorder. In bipolar I, serious episodes of both depression and mania are experienced. Bipolar II disorder also consists of alternate depressive and manic episodes, which are generally considered less severe than type I. Other sub-types also exist.
In order to be given a clinical diagnosis of bipolar disorder, or any other psychiatric disorder for that matter, a set of conditions must be met. Sometimes symptoms fall just below the threshold for diagnosis. This might be due to the erratic or changeable nature of symptoms, or the person may exhibit what might be considered mild symptoms. An example could be the person who feels a surge of energy over a few days, or who becomes over-talkative, or more irritable. Others may experience anxiety or depression. This is “soft bipolar.”
The big debate
A key problem with psychiatric diagnosis is where to draw the line between normality and abnormality. One of the existing criteria is the extent to which a person’s discomfort is actively affecting their life, but even this is tricky.
Here’s an example. Dysphoria is the broad term given to an intense state of unease or dissatisfaction. This is just one symptom considered to be a feature of soft bipolar. Dysphoric hypomania is characterized by irritability and poor judgment. However, such “moods” are also fairly common in the normal adult population, and if we factor adolescence into the mix we see more in the way of agitation, anxiety and depression. At this point the line between what is normal and what isn’t begins to blur.
Then there are the challenges that arise when two or more conditions exist in one patient (co-morbidity). It is estimated that around 50 percent of people with bipolar have a substance abuse problem, but there are other physical and personality disorder issues that already make diagnosis and treatment challenging.
Treatment versus no treatment
Any psychologist or psychiatrist will acknowledge that they see people, almost on a daily basis, who don’t neatly fit into existing diagnostic categories. These sub-threshold cases, as they are often described, represent a clinical dilemma. Should the fact that certain symptoms appear to exist be enough to prescribe powerful psychoactive drugs with sometimes potent side effects?
At present clinicians have no option but to make a calculated guess over whether some form of treatment will be beneficial. In the eyes of many clinicians, for example, the benefits of certain drugs used to treat bipolar symptoms outweigh the risks of those drugs.
Professor of psychiatry Eugene Rubin expresses concerns over extending the boundaries of psychiatric diagnosis, and with it the use of medications. I can only echo his call for more rigorous research into sub-threshold symptoms, rather than undertaking what he describes as a “dangerous leap of faith” when it comes to prescribing powerful SSRIs and other drugs.
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Dr. Jerry Kennard is a Chartered Psychologist and Associate Fellow of the British Psychological Society. Jerry’s clinical background is in mental health and, most recently, higher education. He is the author of various self-help books and is co-founder of positivityguides.net.