Life Sentence in Mind Prison

Why do some people choose mental illness over mental health?

In a previous post, I discussed how mental illness is being dangerously conflated with identity as a means of social validation. I included some thoughts about the way in which diagnostic mental health is at best a heuristic; a form of categorization that is fundamentally facile but sometimes useful as a way of devising interventions. I want to push this a little bit further to demonstrate the way in which mental illness can easily be co-opted by Ideology and subject to the whims of the Current Thing™.

The Prison Courtyard, 1890 (Vincent Van Gogh)

Part I - Signs and Symptoms

Though many in my field speak of Psychiatry as if it were wholly empirical, it is in reality the western medical discipline most removed from any font of objective and verifiable certainty. For example, regardless of the confidence of some business models, brain scans cannot be used to diagnose mental illness on their own. They can be helpful in ruling out other etiologies such as traumatic brain injury or tumor, and they can sometimes be used in concert with other assessments to form a more clear diagnostic picture, but overall we still fall short of the techno-medical vision of “Psychiatrist as vending machine.” That would be the dream, right? To skip the talk therapy. review of symptoms, and family history and instead just put a mind-scanner on your head and get a prescription along with full printout of just how sick and twisted you really are. That printout certainly would be useful when you come into work on Tuesday to be excused for your three-day “mental health weekend” (that happened to coincide with Coachella Week 2).

For the most part, Psychiatry is a branch of medicine focused mostly on observation and interview. A Psychiatrist interviews the patient to determine patterns in their actions, words, and thinking that betray the existence of an underlying disorder. Sometimes an interview is not possible due to significant impairment, and in such a case the provider may simply observe the patient’s behaviors, speak to family members, or read historical notes in order to construct a composite picture of the patient’s condition. No matter the approach, the act of psychiatric diagnosis is ultimately a process of interpretation, e.g., “this patient acts like they have schizophrenia.” I imagine that for most of you, what I have just said is fairly obvious. You already know that Psychiatric diagnosis is based more on inference than deduction, or at the very best a form of abduction. But to say this much is to not say enough.

It could be said that all physicians use both inference and deduction, using both objective and subjective data, to arrive at their conclusions. The approach they choose to employ will vary based on their area of specialty and the context of the presenting patient problem. Urgency is certainly a factor; a doctor might not seek to order a full battery of diagnostic tests if someone is merely presenting with what is most likely a head cold. Conversely, it is obvious that a significant objective case would need to be made prior to amputating a foot. These situations certainly require different levels of discretion, and you do not need to go to med school to know this.

So how is diagnosing Bipolar Disorder any different than diagnosing the common cold? Perhaps we can sense a difference of degree - there is a wider chasm between the severity of the illness and laxity of the diagnostic approach. Given how disruptive something like Bipolar Disorder can be to a patient’s life, arriving at such a diagnosis for such a life-wrecking illness might feel akin to telling a patient they have HIV just based simply on the way they walk. In this sense, Psychiatry could appear to be a bit reductive, arbitrary, or capricious.

But to say this disrespects the psychiatric process. Certainly a Psychiatrist is likely not using state-of-the-art diagnostic technology or advanced mathematics to reach their conclusions, but their process still involves a high level of intellectual rigor. One might even consider their task more onerous than other differential diagnoses that can be resolved with the printed results from a nasal swab. The Psychiatrist must be meticulous in their discovery and evaluation of myriad signs and symptoms to reach their conclusions.

But hold the phone - what are signs and symptoms?

We normally group “signs” and “symptoms” together in a single vernacular phrase that blurs the difference between the words, e.g. “what are her signs ‘n’ symptoms?” The two blend together unconsciously, as in the case of the many persistent tautologies of the English language that we just can’t let go of (e.g., “over exaggerates” or “hoagie sandwich.”)

But there is a difference. A symptom is the evidence or manifestation of illness that a patient perceives (subjective) while a sign is one that the physician perceives (objective). For example, a patient might complain of the symptom of nausea, while the doctor uses various methods of assessment to interpret the sign of hepatomegaly (enlarged liver) that is causing the nausea. A symptom is the report by the patient of an internal sensation or experience that is troubling them. A sign is something that a physician outwardly observes. The hope is that an inventory of these signs and symptoms can, in concert, create a clinical picture of the presenting problem and guide treatment. Yes - the doctor’s interpretation is still definitionally subjective, but the assumption is that the physician’s training and experience creates a framework of credibility and thus pulls it closer to the realm of objectivity.

So again, how is this different in Psychiatry? Well, for some psychiatric conditions it is not. A patient expresses the symptom of needing to get up and walk around a lot, and the psychiatrist sees the sign of akathisia. A patient reports the symptom of being thirsty all of the time and the psychiatrist sees the sign of polydipsia. Put enough of these together and suddenly you’ve got yourself a diagnosis (or pretty darn close). Accordingly, in these two cases, the psychiatrist can also witness the patient pacing the halls or gravitating toward the water cooler. There is an objective that pairs nicely with the subjective.

But what of symptoms that cannot be verified? Again - there is precedence in psychiatry. A patient might stay in bed all day if they’re depressed, or they might not. To determine that one is depressed, the psychiatrist relies on the patient to relay clues of their internal feeling state: “I don’t feel like doing anything” or “I feel so low all of the time” or “I don’t enjoy my hobbies anymore.” The psychiatrist takes notes, compares their notes with others notes, mixes in some clinical judgment, and prescribes a med. In the case of depression, unfortunately, the med probably doesn’t work that well in the long run. But that’s not what this essay is about (don’t worry, it’ll come up later). The point is that the inventory of symptoms is not truly verifiable. Surely we can assume that some patients can over-exaggerate, under-describe, or even outright misrepresent their symptoms. Moreover, even the fairly objective previous examples of polydipsia and akathisia can be faked, as can a manic episode, a psychotic break, or even Parkinson’s if you’re so inclined. I suppose medical diagnoses can be faked as well, but it would take a little bit more to fake a rectal bleed than it would be to fake, say…being sad? Simply put, psychiatric symptoms don’t usually show up as things we can plainly see like rashes or fractures or skin growths. They show up mostly as testimony, personal tales of misery as told by the miserable.

In this way we can start to draw a little bit clearer distinction of how the psychiatric process is different. In legal terms, psychiatric diagnosis depends more on testimony than on the proverbial “Exhibit A.” As we know from footage of many publicized court cases, sometimes people fake it for their own personal gain. Public accusations of inauthentic courtroom behavior are basically a national pastime. Even those who engage in the reflexive, automatic acceptance of any and all declarations of trauma or illness still freely pass judgment on the emotional authenticity of testimony in the context of a court case.

Even so, we could reasonably guess that faking a more severe illness just doesn’t have a high level of payoff. I could pretend to have Alzheimer’s disease but it most certainly would be a miserable social choice to make, considering I would most likely be remanded to a care facility and have my assets transferred to my family. But what of those maladies that require a lower level of investment for a still reasonably high payoff? Do I really have to go out of my way to prove that I’m depressed?

Sir Edward Herbert, Later 1st Lord Herbert of Cherbury (1581/1582–1648) by Isaac Oliver

When I was a kid I didn’t know anyone who was depressed. Per a recent conversation with my 12-year old nephew “pretty much everyone has depression.” My nephew is a sharp dude, but certainly not yet a qualified epidemiologist. So what are the actual numbers on this? This seemingly reliable source says around 28% of people in the United States have experience depression. This is about 14 times higher than the amount of people in the US with red hair. A retrospective study on the incidence of depression (conducted by physician-researchers from Harvard and Mass General) show a rate of depression between 2 and 5% in the 50 years between 1950 and 2000. How could the last two decades see such a massive shift?

Yes, there’s of course the operating narrative that the veil of stigma has been pulled down and people are free to talk about it more, we have better diagnostic strategies, people in non-medical positions are more trained to spot it in the schoolyard and workplace, etc etc. But even with all of that in mind - does not the sheer magnitude of the illness blow your mind? How does our country operate on a day-to-day basis if over a quarter of us suffer from this "epidemic" of depression?

Another question: what does it mean when an illness is widely defined by having less-than-average numbers of certain neurotransmitters when around 30% of people have the illness? Ignoring for a moment that the Serotonin-Mood hypothesis is tenuous science at best and a marketing ploy at worst, wouldn’t the average (qua “arithmetic mean”) amount of Serotonin shift if raw data inputs were so significantly decreased across the board? Does not this conundrum alone give us even the slightest cause to crack the door even a little toward the possibility that perhaps this thing is not an illness?

I think not; the days of simply saying we are taken by a bout of melancholy are in the past. There is much to be said about this cultural shift in terms of over-medicalization, marketing, pharmaceutical greed, positive psychology, self-help, wellness culture, and a myriad other influences. At the end of the day, some ratio of all of these things swirl together to formulate our current cultural situation in which many people are simply obsessed with being mentally ill. But again - those are essays for another time. The purpose of this essay is to examine the way in which mental illness is being used by the powerful to construct a new ideology.

Part II - Ideology