So, why did you select Psychiatry?

[clausewitz2]

This begs the question, what is an illness?

This begs the question, what is an illness?

Oof, a big question that I was trying to avoid getting into above. I think "disease" is easier to tackle and maybe clearer but using the phrase "mental disease" has associations with some very nasty strains thought historically. I was trying to pick out the concept of mental illness and keeping focus more narrowed for this discussion. But understandably the phonemic resemblance to "illness" is hard to shake.

There was a trend in some corners of linguistics to make this sort of use of course language terms in highly precise ways obvious by using an arbitrary name instead. So if it helps, mentally substitute "Bob" for "mental illness" with the definition I offered above. I prefer to treat Bob.

I will restrain my inner pedant and not throw down about how this is not really begging the question in a logical sense.

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[Shufflin]

Oof, a big question that I was trying to avoid getting into above. I think "disease" is easier to tackle and maybe clearer but using the phrase "mental disease" has associations with some very nasty strains thought historically. I was trying to pick out the concept of mental illness and keeping focus more narrowed for this discussion. But understandably the phonemic resemblance to "illness" is hard to shake.

There was a trend in some corners of linguistics to make this sort of use of course language terms in highly precise ways obvious by using an arbitrary name instead. So if it helps, mentally substitute "Bob" for "mental illness" with the definition I offered above. I prefer to treat Bob.

I will restrain my inner pedant and not throw down about how this is not really begging the question in a logical sense.

You know there's room to discuss the definition of what constitutes an illness without becoming overly pedantic and philosophical about it. We had to do this where I studied medical ethics in Cambridge. But not relevant here to this thread. And sometimes the best revelations are had when questions are posed without logical prompt.

 

[deleted736562]

We rely on the moral weight of our pronouncements to label things as pathological or non-pathological, so I think it is incumbent upon us to apply a relatively conservative definition to what we are comfortable calling an illness and applying a medical model to. When you examine literature about the extent to which many non-symptom related factors determine who gets what kind of diagnosis (e.g. being black is an independent risk factor for being diagnosed with schizophrenia v. bipolar or psychotic depression), I think you are forced to this position if you are interested in intellectual integrity.

But this is not specific to psychiatry. The concept of "pathology" or "disease" itself is not easy to define, though it seems that way. The concept of illness is actually more useful. In a way, "pathology" imparts a value judgment on an objective process and so we already are in uncertain murky waters. With "illness" you know you're dealing with human experience.

At the end of the day, all of medicine deals with distress and functionality; that is fundamentally the reason why people seek medical care, regardless of specialty. So imo fundamentally it all comes down to a subjective criterion and psychiatry is not special in that regards.

The difference is that in psychiatry we do not understand what makes people behave in certain ways so we can help people; the scientific basis remains very tenuous. The DSM categories try to make sense of that behavior in "discrete categories" but this does not map up well to the variability we encounter in clinical practice. There may be similar situations in all of medicine where people struggle to define diagnoses and map them to processes in the real world.

It may be possible that it will not be helpful to organize behavior into discrete categories in the first place because there are simply so many factors that are at play and those factors interplay with each other to a certain level of complexity that are quite unique to each individual.

 

[clausewitz2]

But this is not specific to psychiatry. The concept of "pathology" or "disease" itself is not easy to define, though it seems that way. The concept of illness is actually more useful. In a way, "pathology" imparts a value judgment on an objective process and so we already are in uncertain murky waters. With "illness" you know you're dealing with human experience.

At the end of the day, all of medicine deals with distress and functionality; that is fundamentally the reason why people seek medical care, regardless of specialty. So imo fundamentally it all comes down to a subjective criterion and psychiatry is not special in that regards.

The difference is that in psychiatry we do not understand what makes people behave in certain ways so we can help people; the scientific basis remains very tenuous. The DSM categories try to make sense of that behavior in "discrete categories" but this does not map up well to the variability we encounter in clinical practice. There may be similar situations in all of medicine where people struggle to define diagnoses and map them to processes in the real world.

It may be possible that it will not be helpful to organize behavior into discrete categories in the first place because there are simply so many factors that are at play and those factors interplay with each other to a certain level of complexity that are quite unique to each individual.

While I do not disagree at all with the notion that all medicine is about functionality and distress, I think it is important to recognize the subset-superset distinction. Not all functionality and distress are usefully addressed by medicine. While it is an empirical question in some sense, I think it would not be hard to sustain the proposition that the extent to which particular functionality and distress are best addressed in a classical medical model is just to the extent that they share the features I laid out.

The very tenuous grasp we have on mechanism and etiology is exactly what should make us conservative about what we designate as genuine, medical disease entities. I would suggest we limit ourselves to cases where we have a very firm grasp of heredity, course, prognosis, treatment-response, phenomenology, etc. This is how we avoid pathologizing human behavior excessively (you are absolutely right that "pathology" is a loaded term, but that is what we are proclaiming when we say So and So has Such and Such a disorder). Other specialties struggle with this issue as well, as I said above, but there is a continuum of resemblance to the prototypical case I laid out above. And we are mostly at one end.

I think classification and categorization are necessary if we will ever make progress in actual treatment. The natural history at a sufficient level of detail of any medical condition will be strictly speaking unique, as will the precise interaction of risk factors and such. Every cancer will have a specific timeline and combination of mutations, a specific spatiotemporal pattern of spread, etc. But you can extract regularities across cancers and make chemo work. More research on more specific, empirically derived endophenotypes might give us better understanding, but the DSM categories at present are not at all that.

For entities like GAD or MDD, none of the criteria i outlined above are really met. They are just too heterogenous to be useful. Furthermore, symptom checklist definitions that are agree upon by committee genuinely do beg the question of why this pattern of behavior rather than that should count as a disorder. "Well, because those are the criteria for the disorder." "But why are those the criteria?" "Because they are reliable." "But reliable for identifying what?" "The disorder."

You get away with this if you are really picking out uncommon patterns of behavior. If you are in fact describing something most or a large fraction of people go through, well..

 

[psych_pa]

Why can't people have brief periods of mental illness for things such as anxiety and depression? Just because you got pneumonia once doesn't mean that you'll always have it. It just means that 'oh dang there was this one time when my lungs hated me'.

I believe people can have brief periods of anxiety and depression, for sure. I would not diagnose this as an anxiety disorder or a depressive disorder, though. I think the F43.21 and F43.22 are highly underutilized. Therapists as well as physicians are quick to call it a more severe pathology than what it actually is, maybe for lack of time or whatever... I do not work in private practice so folks here are often very brief upon assessment. It's a "get them in, get them seen, move on" place.

For instance, I work in a prison and if something terrible happened to me and I found myself in prison for some reason, there is no doubt in my mind I would lose sleep for nights on end, I would be highly irritable, severely depressed, not want to get up out of bed, cry often, worry constantly about my future, isolate myself from others etc... But I do not feel that should be diagnosed as a depressive disorder or an anxiety disorder. I feel this would be considered normal issues with adjusting to the environment and circumstance, but the number of times I see folks automatically slap a "generalized anxiety disorder" on a patient immediately upon intake assessment is astounding. The patient often would also vocalize not having any symptoms such as this before incarceration, and therefore often would not even meet the criteria of having symptoms for 6 months.

This is just a general rant on the variability/inappropriateness of diagnosing. I digress.

 

[Dharma]

This should jump out at you as indicating something seriously wrong with some of the ways in which we conceptualize mental illness if true.

Agree. Most are not necessarily mentally ill per se, but simply annoying yet somehow they end up in my clinic. So, not pathological in the medical sense (so why are you in my clinic?). These people are everywhere.