Categorical and Dimensional Diagnoses

I recently had the great pleasure and privilege of speaking to a group of health care providers in Monteagle Tennessee, and an interesting question came up. The sick citizens of Tennessee are having a hard time now because of the problems with TennCare. This problem is not new, and is not only happening in Tennessee. There is no malice or lack of compassion involved, it is simply a matter of $$$.

And because we need to have a diagnosis in order to apply for reimbursement, the discussion soon turned to the matter of psychiatric diagnosis. It’s pretty well known that I have lectured on the subject of psychiatric diagnosis all over the world: it was actually one of the reasons that I was first invited to come to the United States. The problem is this. When we classify an illness, we can either think of it as a “category,” like strep throat or a heart attack: an illness that has clearly defined margins. Or we can think about it as a “dimension.” So instead of seeing illness as a separate entity, we think of health and illnesses as lying on a spectrum, running all the way from being healthy and well, through mild degrees of just not feeling “right,” to being severely ill. Reimbursement requires categorical diagnoses, even if they do not reflect clinical reality.

This second – dimensional - way of thinking is particularly useful when we are thinking about psychological problems. The world is full of people who are a little bit obsessive, or who get bad mood swings. But they are not bad enough to be called an “illness.” In fact, having some of these traits can be enormously beneficial: they have continued in the population because they have a survival advantage. If I need to have surgery, I sincerely hope that my surgeon will be mildly obsessive, rather than discovering a few weeks later that he had forgotten to do something he should have!

When I am teaching about schizophrenia and bipolar disorder, I discuss how they lie on a spectrum that passes through so-called schizoaffective disorder, cluster A personality disorders – schizoid, schizotypal and paranoid – to schizophrenia. (You may be interested in looking at the blog entry for May 24th here). I also make the point that I can make just about anyone psychotic. Come and live in my research center for a week, where you will not be allowed to eat or sleep; you will have to drink 30 cups of coffee a day and take up smoking. I can guarantee that most people will develop some symptoms. If you have a family history of mental illness it would not take a week, but perhaps 3-4 days. And if you have a personal history of mental illness, it could take no more than a day or two. The key is arousal. People experiencing high levels of arousal may well start to experience manic, depressive or psychotic phenomena. The types of symptoms that are experienced are determined by background, environment and genes. This sort of “reactive” psychosis is completely different from the other end of the spectrum, where, particularly in males, there are demonstrable abnormalities in the brain – shifts in laterality and progressive loss of grey matter in specific regions, with swelling in other – many of which are present before the onset of full-blown psychosis, and before exposure to medications. Though some of the older antipsychotic medicines may make the situation much worse.

In January of 2005, some of my colleagues in Edinburgh, Scotland, published an important paper after studying people at high risk of developing schizophrenia. Many of these high-risk people did not develop the illness, although some had transient and partial symptoms. We know that some family members – the carriers of the genes – may also suffer from some symptoms of the illness. This shows us how genes do not control everything: many people suffer from mild cases because their environment or personality helped protect them from developing a full-blown illness. In other words: biology is not destiny. These findings also give us important clues as to how we may be able to reduce the risk of an illness expressing itself.

Diagnoses are not always cut and dried. Medical professionals are sometimes unable to reach a definitive diagnosis, needing to wait and see how things develop. Having specialized in the diagnosis and treatment of tough cases, family members sometimes become very upset because their loved one does not have a clear diagnosis. Psychiatric diagnosis is still primarily clinical and often needs time to clarify. Although there are many demonstrable neurological disturbances in people with schizophrenia and bipolar disorder, even the most sophisticated brain scans are still not at the stage where we can make diagnoses.

If we think in terms of dimensional diagnoses that reflect clinical reality, it helps us to understand the range of symptoms that people can experience. It also speaks to the point that I have made time and again: symptoms are signs, and they are signs that can be generated in the body, in the mind, in relationships (not just because some might be stressful), and they may have subtle system or spiritual origins. Successful treatment needs us to identify the origins in an individual and to work with all the five main dimensions of the individual.

And by the way, we have succeeded in helping virtually all of our seriously mentally ill patients back to living the kind of lives that they want: jobs, relationships and so on. So this is not an academic discusssion, but instead something supremely practical

Technoratic tags:diagnosis category dimension bipolar disorder schizophrenia schizotypal personality disorder recovery spirituality

Comments

[spiritual_recovery]

Richard: "It also speaks to the point that I have made time and again: symptoms are signs, and they are signs that can be generated in the body, in the mind, in relationships (not just because some might be stressful), and they may have subtle system or spiritual origins. Successful treatment needs us to identify the origins in an individual and to work with all the five main dimensions of the individual."

I suspect it is the rare practioner who approaches psychosis from that multi-leveled aspect, yet my own experience reflects precisely this degree of complexity. What seems to be more typical is that caregivers focus on one aspect, i.e., neurological, and attempt to address the range of the experience from that exclusive vantage point. In western culture this nearly always means a period of hospitalization and a sustained, perhaps life-long, period of psychiatric medication.

A nod is often given to the wholistic model via recognition of other modes of therapy such as CBT, re-employment training, or addressing side addictions, but acknowledging the positive or spiritual aspects of the psychotic experiences seems to be shunned as "feeding the delusions". While this approach seems to be effective in some instances, it is hardly successful in all. Nor does it address puzzling questions such as why some individuals in other cultures -- and more of them -- get well without hospitals, medication, doctors, or therapy.

Confusing the issue is we do not even have a clearly identified cause at this point in time. In the past few months alone I've read reports of schizophrenia being caused by milk, a virus in cat poop, bad parenting, stress, genetics, trauma, child abuse, marijuana, acute sensitivity, a transformational shift in consciousness, fragmentation of ego boundaries, neurological deficiencies, and more. It's as if we have a hammer and 27 different kinds of nails.

My own recovery began with the experience of psychosis itself. It continued via the process of drawing out the meaning within that experience. Although psychotherapy is rarely considered to be a form of effective treatment, I have consistently found that the work of the Jungians and transpersonal therapists have contained the most significant insights for me. Everything that I needed to get well was contained within the roots of my experience.

Overall I'd say that the bulk of my recovery occurred over a three year period. I was not hospitalized, I did not see a psychiatrist or psychologist for that experience, nor have I been on any form of psychiatric medications [neuroleptics, mood stabilizers, anti-depressants or anything else]. I have been working for three years, my relationships are all stable and my mental faculties appear to be intact. I would say that I am well and I think most people would have a difficult time arguing that I am not.

[Richard Petty]

I am delighted to hear about your recovery, and that ultimately the whole experience was positive.

Sad to say, it is still the exception. I have seen well over 10,000 people with psychotic symptoms, and I'm always very alert to the possibility that folk may be having some form of spiritual awakening or kundalini experience, but I've seen very few, despite getting a large number of referrals from priests, psychics and spiritual teachers. That being said, it is essential to respect and work with a person's spirituality. Indeed I have always insisted on having ready access to some kind of chaplain for those who want it.

Even if someone has a diagnosis of schizophrenia - and you have read my comments about diagnosis - at least 10% do recover completely. A fact that is often not advertised.

The list of possible causes of psychosis is long. But I think that one of the most common fallacies is what I call "Uni-causality." I talk about that a lot in my last book. There are extremely few problems that are caused by just one thing. The marijuana story is a good example. Smoking it during the vulnerable perod of brain development (roughly ages 14-18) is when it can be dangerous. Smoke it more than 50 times by age 18, and the rate of psychosis in the twenties is six times higher than the general population. But there almost certainly has to be a genetic predisposition as well. Plenty of people have smoked marijuana with impunity. This relationship is not self-medication: it's not been spotted with any other drug, thugh we are getting very worried about crystal meth.

Some of the potential causes like winter births, child abuse and bad parenting have all fallen away as empirical research has continued. When I first arrived in the United States I met a well-known figure in the National Alliance for the Mentally Ill. He announced that he was not going to like me because I came from the same country as RD Laing who had caused so much heartache. My riposte was to say that I was English, he was a Scot and nobody took his work seriously anymore. Though as a student in the seventies, his books were required reading.

I have been very interested by the new data indicating that being born and raised in a city dramatically increases your risk of developing psychosis, particularly since schizophrenia was very rare until about 1750, when it suddenly increased all over Europe.

It is clear from your writing that you are cognitively fine. That also is a great blessing: I have seen too many people who went without treatment and paid the price in the brain. I well remember a young man in his early forties, whose IQ had fallen from 108 to 64.

You may perhaps be interested to see some of the articles on http://psychiatricresourceforum.blogs.com/
I contribute a fair number of them.

I'm going to continue rummaging around your website, and I will probably have more to say when I've finished.

Kind regards,

RP

[spiritual_recovery]

"Even if someone has a diagnosis of schizophrenia - and you have read my comments about diagnosis - at least 10% do recover completely. A fact that is often not advertised."

Yes, I have read your comments and would agree the issue of recovery is frequently de-emphasized. I'm not certain why this is -- perhaps it's out of respect for those who don't recover. And yet, we don't do the same with those who are suffering from any other form of debilitating illness. Why then would we not try to instill hope in someone with schizophrenia? I remain mystified by this aspect of care in this culture.

Meanwhile, I still have many questions of my own, not solely for myself but also for the people that I talk to or have spoken with over the past few years.

You are more than welcome to rummage through my site. As per schizophrenia and spirituality, you may enjoy the articles by David Lukoff in particular. [Spiritual Emergency blog]. On the matter of recovery, I would wish to draw your attention to the work of John Weir Perry and Jaakko Seikkula. [Spiritual Recovery blog] Perry's recovery rate was in the range of 85%, Seikkula's is the same. Perry was a Jungian who believed that the schizophrenic episode is an attempt at self-healing; Seikkula is a clinicical psychologist who has developed an approach he calls Open Dialogue Treatment. Essentially, both men rely on forms of "talk therapy".

Meanwhile, I will be happy to check out that forum and your articles there. I thank you kindly for the link.

Regards,

s_e

PS: R.D.Laing seems to inspire extremes of dislike or admiration. Admittedly, some of my favorite stories about psychiatrists feature R.D. Laing.