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April 07, 2007

A Coincidence...and an Insight

An article by  Dr. Jerome Groopman on Bipolar Disorder appearing in the latest (April 9) New Yorker immediately caught my eye; it had arrived right after I’d posted my latest rant on the shortcomings of the DSM. It was therefore no surprise that it supported my contention that the system of classification that has been uncritically embraced by modern Psychiatry is both confusing and misleading. However, I wasn’t prepared for the fresh insight it (unwittingly) provided as to why the DSM misses the mark and how the conditions it attempts to classify might be more usefully  considered.

Dr. Groopman is both articulate and prolific; he’s been the New Yorker’s medical writer since 1998 and somehow finds time for a day job as distinguished Harvard educator and researcher. Also of interest: he’s just published a book on the cognitive process in Medicine, one I’ve yet to read but have seen described as a critique of traditional medical thinking and a plea for clinicians to question certain commonly held assumptions. Ironically, the fact that he didn’t follow that advice in the bipolar article is what may have provided me with the insight needed to more precisely describe the DSM flaw I’ve always been troubled by.

Groopman’s article is focused on a specific controversy that surfaced within Psychiatry during the Nineties: does an entity once known as ‘Manic Depressive Psychosis’ occur in children? Before it was renamed ‘Bipolar Disorder,’ Manic Depressive Psychosis had been thought to affect only adolescents and adults. The intramural dispute over the question of pediatric involvement apparently didn’t surface until after promulgation of the bipolar label and specific criteria for its diagnosis by DSM-IV (1994). Since then, and very much in keeping with our present era’s internet advocacy, an ‘explosion’ of interest has occurred. A Google search of just the term, ‘bipolar,’ generated over twenty one million hits, with the vast majority found on the first ten pages clearly aimed at potential ‘patients.’

To return to Dr. Groopman’s New Yorker article, it’s  based mostly on his extended conversations with a number of recognized experts in academic Psychiatry. Although their quoted comments reveal an ambient confusion over the precise diagnosis of Bipolar Disorder and are, at least implicitly, critical of the role played by an ascendant DSM as reigning diagnostic authority, all those quoted clearly accept the idea that’s also implicit in the DSM itself: the classified entities can be as accurately pigeon-holed as the diseases described by pathologists. There is a further critical implication that those entities, once described (discovered?), will all behave like somatic diseases; in other words, they will persist and tend to progress in some characteristic fashion unless ‘effectively’ treated.

To return to the Google exercise, what one can recognize quite clearly is an attempt to advertise both a new ‘disorder’ and its treatment. As is pointed out in one description of Bipolar Disorder after another, the 'symptoms' of elation and depression are characteristic of emotions manifested, to some extent, by all of us at various times. In other words, there is nothing about them as absolutely characteristic (pathognomonic) as the histological characteristics which allow pathologists to separate most physical diseases from each other with complete confidence. The implications of that statement are of great significance for the following reasons.

The diseases that have been systematically studied anatomically, histologically, and biochemically by pathologists from the time of Virchow can be analyzed with considerable confidence as separate entities with reference to cause (etiology),  clinical course (pathogenesis), outcome, and response to treatment. None of those assessments are possible in conditions for which no objective diagnostic standard exists, which is an apt description of all the entities classified in the DSM. Isn’t it just as possible that the psychiatric 'symptoms' upon which DSM nosology is based reflect variable emotional tendencies that are both inherited on a genetic basis and expressed in variable fashion in response to the plethora of widely varying environmental influences that affect all humans?

That latter description is a far more accurate picture of the behavioral ‘reality’ disclosed thus far by systematic questioning of the population of cannabis users I’ve been both studying and attempting to describe.

Doctor Tom


Posted by tjeffo at April 7, 2007 06:57 PM