The Doctor Is In: All disorder is not disease

The Doctor Is In is an occasional series where JHU Press authors discuss the latest developments and news in health and medicine.

Guest post by Robert N. McLay, M.D., Ph.D.

Where is the line between disease and health? To many people this might appear a silly question. The guy hacking up a lung is sick. The person running the half marathon and smiling is perfectly healthy. But take a step back. Think about things like the aging process. When does normal age-related memory loss turn into Alzheimer’s? How about developmental issues? When is being short considered dwarfism. Diet? What exactly is the difference between being “morbidly obese” or a little overweight? Now step into the biggest morass of pathology versus normality, mental health.

A series of recent editorials in The New York Times, The Washington Times, The Huffington Post, and elsewhere have illustrated the practical and political difficulties surrounding mental health diagnosis. The opinion columns are up in arms both about diagnostic labels being given for what are often thought of as normal emotional reactions, and about individuals who were told their issues were not Axis I Diagnoses, but rather part of their inherent personality structure.

First, the story of Army Captain Susan Carlson. Carlson is a military mental health provider. She, however, found herself on the other side of the diagnostic-labeling machine when she was diagnosed with a personality disorder. Captain Carlson joined the military late in life. After her deployment, her superiors felt that she was not adapting properly. She was charged with sexual harassment of an enlisted member, and, by her own admission, was “not a strong soldier.” Her chain of command referred her for a psychiatric evaluation. It is disputed whether this was to determine if she suffered from a personality disorder or whether her command strong-armed the psychiatrist into making a diagnosis of personality disorder so that they could get rid of her.

Although personality disorders are diagnosed by a psychiatrist, they are classified in such a way as to indicate that the mental health establishment doesn’t consider them diseases. What the military is essentially saying to Captain Carlson is,  “You aren’t really ill. Your personality just doesn’t allow you to properly adapt to deployment.” If the diagnosis of personality disorder is upheld, Carlson would likely be kicked out of the Army–without a medical retirement that some estimate to be worth $1.5 million. That a service member who suffered a mental breakdown in a combat zone should be denied benefits naturally makes many people angry.

The converse of this situation is evident in the outrage over the potential inclusion of pathological grief as a diagnosis in the next edition of the Diagnostic and Statistical Manual (DSM). That sadness and loss can be classified in the same way as a condition like schizophrenia may seem offensive. Many see this as an attempt by the pharmaceutical industry to push more pills down our throats, or, at the very least, an attempt to classify normal reactions as mental illness.

The concepts of “normal personality” and “natural reactions,” however, can lead to very poor outcomes.

In the debate over pathological grief, a colleague pointed out that one reason that military Post Traumatic Stress Disorder (PTSD) might not respond to traditional treatment could be because we misdiagnosed service members. They might really be struggling more with grief than trauma. If we had studied grief as its own condition, we might know more about the best way to help people who are suffering with their loss. Only time will tell if this approach is fruitful. We already know, however, that despite being classified as having personality disorders, many individuals so labeled benefit greatly from medication and therapy.

Not all disorders may turn out to be diseases. Nevertheless, using the medical model–recognizing patterns and using them to guide treatment–can be helpful. Doctors knew how to treat the flu long before we knew that there was a virus that caused it. In my book At War with PTSD, I point out that PTSD itself can in many ways be viewed as a normal reaction to abnormal events. It is normal to bleed if you are shot, but that does not mean that it is healthy. Such a normal reaction requires treatment. The treatment might be medication; more than likely it will be therapy. Perhaps it will be something altogether new. Regardless of the type, the treatment will work or fail regardless of how we classify the problem. All that is required is that we recognize it.

In the end, what I am arguing is that the distinctions between illness and health are more artificial than we realize. Focusing on “is someone really sick?” can distract us from the more important question of “what does this person need to be fully healthy?” If there is a condition, disease or not, that shortens lifespan or prevents someone from living life to its fullest, it should be addressed to the fullest extent possible. Focusing on that might be healthier for us all.

Robert N. McLay is a psychiatrist and research director with the Naval Medical Center San Diego. He came on active duty in the United States Navy in 2001 and shortly after the start of the war in Afghanistan became primary investigator on two Navy programs involving virtual reality treatment for PTSD. His book, At War with PTSD: Battling Post Traumatic Stress Disorder with Virtual Reality, will be available from JHU Press in April 2011. The views expressed in this guest post belong to the author and in no way reflect the official opinion of the JHU Press.

The information provided in this blog post is not meant to substitute for medical advice or care provided by a physician, and testing and treatment should not be based solely on its contents. Instead, treatment must be developed in a dialogue between the individual and his or her physician. This post has been written to help with that dialogue. The services of a competent medical professional should be obtained whenever medical advice is needed.