Aren’t We All Somewhere on the Spectrum of Disease?

By HANS DUVEFELT, MD (7)

The other day I saw a new patient who used to be on Lamictal, a mood stabilizer. The young man explained that he had gone through a difficult time in his life a few years ago and his primary care doctor put him on Prozac, which, as he put it “hijacked” his brain and made him “ugly, hyper and careless”. The man immediately stopped the Prozac and his doctor prescribed Lamictal, which he stayed with for about a year.

He decided to stop the new medication, because he reasoned that he didn’t have any psychiatric issues. It was just a side effect of the Prozac, which he in retrospect probable hadn’t needed at all.

Since then, he admitted, he had felt sad or unsettled in the spring and fall, but it always passed and he didn’t think his wife or anybody else noticed his seasonal mood changes.

“So, did anybody actually use the word “bipolar” in talking about what you went through?” I asked.

He winced and almost seemed teary eyed. “Yeah, but I don’t think that’s right. How can you put a label on somebody that will follow them for the rest of their life because of what their brain did when, basically and literally, they were on drugs?”

I nodded.

“Who knows how many people might react the same way if you give them Prozac”, he continued.

“I think labels can hurt sometimes, but they can also be a way of understanding how our minds and bodies work”, I began. “I don’t believe diagnoses are as cut in stone as some people like to think.”

He looked quizzical as I continued:

“Take diabetes – this country and Canada have slightly different cutoffs for what a normal blood sugar is. Or blood pressure – every few years the experts pick a different number for what’s good enough and what’s  ideal. I believe most things we call diseases are points at the extremes of a spectrum that we all fall somewhere on.”

Now he was the one nodding.

“Take mood”, I continued. “At one end of the mood spectrum there is depression and at the other there is what we call mania. Sometimes that looks like exaggerated happiness and confidence, but sometimes it is more like irritability and agitation. We can all experience any one of those moods, but usually we are somewhere in the middle. So, people are making up disease definitions depending on how far and  for how long we deviate from the middle. But if we never move an inch from neutral, that’s not necessarily being healthy – I think of that as definitely abnormal.”

“I see what you mean”, he nodded again.

“As a clinician, I think of labels as a type of shorthand or mental image that I keep in mind when I approach a problem. They help me choose treatments and they help me explain things. But I tend to be slow in sticking labels on patients or in their medical records. I read a book once called ‘Shadow Syndromes’ that makes the point that looking at the extremes of whatever spectrum we are on helps us understand ourselves and can be very empowering.”

“So, Doc, do you think I’m bipolar?” He leaned forward.

“You have the tendencies, yes, but a condition isn’t a problem until someone sees it as a problem. If neither you nor the people around you see your mood variability, not to use the stronger word ‘mood swings’ as a problem, then fine. But I, knowing what you’ve told me about how your brain works, would be a fool to prescribe Zoloft or Lexapro if you ever came to me feeling terribly depressed. I would then think of you as somewhere on the bipolar spectrum, needing a slightly different treatment approach if we wanted to lift your mood.”

“A mood stabilizer, like Lamictal”, I finsished, “can be like an insurance policy against ever having a manic episode in the future, and we usually recommend long term treatment if a person has had an episode out of the blue. But I’m not so sure it’s necessary if the episode was triggered by Prozac or any other antidepressant. I’m sure there are lots of opinions about that, but that’s what I think, especially since your episode was not severe from what you’ve told me.”

On my drive home that afternoon, I thought of the spectra I may have moved along during my lifetime. I remember my mother commenting on how I had turned into such a slob; “When you were little you were so neat, you used to line everybody’s shoes up in the entryway.”

That’s the OCD spectrum, and I guess I narrowly escaped that diagnosis…

Hans Duvefelt, MD is a primary care physician based in Maine. He blogs at a Country Doctor Writes. This post is exclusive to the Deductible. His first book “A Country Doctor Writes: Conditions – Diseases and Other Life Circumstances” is available from Amazon.com

7 thoughts on “Aren’t We All Somewhere on the Spectrum of Disease?

  1. I’ve always thought about mental illness in this context – we define it as illness because of negative consequences, but it’s really just the deviation from a norm. I think Elon Musk is the best example of this – even ignoring some of his childish Twitter behavior, the guy’s brain is waaaaaaaaay far off from the normal human brain. He thought he could start an electric car company from scratch and be successful. That’s… crazy. And yet, because he’s been successful at it, we don’t label him as mentally ill.

    The really interesting cases are people like artists – David Foster Wallace committed suicide because of his depression, but only after creating one of the great works of American literature. We label him as mentally ill for his depression, but we don’t really have a label for the positive side of the fact that his brain was far from an average brain.

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  2. Well yes. But that shouldn’t be much of a surprise to anyone, humanity isn’t made of absolutes or boxes or borders.

    A spectrum you can be ‘on’, as the word suggests, is just a range or a degree within a classification so we have a common concept when communicating about things. If we had to develop a new word for every unique combination of attributes it would become very hard to talk about things.

  3. Not only are we all somewhere on a spectrum, we’re on a linear combination of different spectra.

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  4. As far as I understand, this kind of thinking is especially visual with Diabetes.People have different levels of insulin sensitivity, which changes over time with thing such as diet and excercise.

    Then magically one day you cross some arbitrary barrier, and you have type 2 diabetes. Crazy.

    Only recently has this even been taken under scrutiny, and the phrase “pre diabetic” is used more. But it’s clearly not enough.

    I think the key to unlocking this is getting more people into measuring their insulin sensitivity through products like Veri[1]

    [1]https://www.veristable.com

    1. I think measuring insulin levels is belaboring the obvious. Why eat the wrong things and checking lab work to see if you’re getting away with it? Just do the right thing! Don’t eat “typical” amounts of bread, pasta, cereal, crackers etc.

  5. This is a really dangerous and misleading way to look at bipolar. The disease proper of bipolar disorder is progressive and degenerative. This progression is accompanied by structural changes in the brain [1] as well as biological changes in the body [2].

    If someone had the syndromes of manic or depressed symptoms in response to a medication, that does not prove either way that the person actually has the progressive and degenerative disease that can induce those syndromes spontaneously. If withdrawing the medication completely solves the problem, it simply indicates that they don’t have the disease.

    The sentiment of “we’re all a little crazy” is very old, and very dangerous to go around repeating. There’s a specific threshold where things suddenly get orders of magnitude more fucked up, and anyone who has crossed this threshold will know how damaging it is to treat these diseases as if they’re just an extension of normal human experiences.

    If you have this disease, you need to halt the degenerative process. I’ve taken my meds every single day for the last 14 years because I know what will happen if I stop. I have friends and family that went down that road, and it isn’t pretty.

    [1] https://www.sciencedirect.com/science/article/abs/pii/S00063… [2] https://www.sciencedaily.com/releases/2016/05/160531104421.h

  6. I think lay people and some doctors are quick to use the label bipolar. My point is that the labeling of mood swings as bipolar is sometimes medicalizing normal or near normal moods. The primary care doctor in my vignette was quick to use the bipolar label in a person with very mild symptoms to begin with. If you’re saying I’m claiming we’re all a little crazy and that this is a dangerous thing to do, I disagree. I think we all have moods that, IF SEVERE AND FREQUENT, could earn us a diagnosis. That doesn’t mean we’re a little crazy with the magnitude of the “symptoms” we exhibit. What I do believe, very strongly, is that lesser degrees of behaviors and emotions with medical names if severe, SHADOW SYNDROMES, can help us conceptualize things while they don’t give us the right to attach labels.

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