How Well Do We Really Understand Mental lllness?

How often are you satisfied with the diagnosis you arrive at?

There are times, as with the patient who had thoughts of killing her child, where the diagnosis is incredibly important. There are other times when diagnosis is less important than treatment. Lauren had numerous diagnoses given to her at various times—bipolar disorder, borderline personality disorder, depression, anxiety—and all along, she was essentially doing the same thing. So it didn’t much matter in her situation what her diagnosis was. What mattered was trying to determine what was driving her behavior and how we could interrupt this terrible cycle.

You write, “It’s difficult to separate symptoms from the social stressors that exacerbate them.” Can you talk about this?

There are often psychiatric symptoms—depression, anxiety, hallucinations—that go hand in hand with the fact that our patients are experiencing incredibly stressful things in their lives. Someone might be hospitalized because they are depressed and suicidal. That person may have just lost his job and have a wife who’s threatening to leave him. It’s very difficult in those moments to tease apart what is disease and what is circumstantial. So many of our patients have homelessness and trauma and substance abuse that it’s difficult to separate illness from context.

Kendra's Law, enacted in several states after an untreated schizophrenic man pushed a woman to her death on a subway platform in New York, is a controversial measure that makes outpatient treatment mandatory. What do you think of the ethics here?
Taking away someone's autonomy is always an uneasy balance.  Nonetheless, in my work with the chronically and persistently mentally ill, I've all too often seen how periods of treatment nonadherence can extend patients' symptoms and suffering, and can sometimes put them in real danger.  I've treated many patients who have been tormented by paranoia or besieged by hallucinations, and without treatment their symptoms simply do not remit.  Once court-ordered treatment is implemented, I see people begin to emerge from deep distress, often with great relief  Because their fear-inducing symptoms diminish, their quality of life begins to increase dramatically.  I write about this in Falling Into the Fire in terms of involuntary hospitalization.  Compelling patients to obtain treatment is a tool we must use sparingly and only when appropriate to do so.  But refusing to ever compel treatment is short-sighted, as doing so can allow a patient's illness and suffering to persist under the guise of preserving autonomy.

You juxtapose scenes at the hospital with scenes of your life at home. What has your experience as a psychiatrist taught you about your own life?

I feel like I have a much deeper understanding of the capacity of the mind. There was a moment I had a deep fear of dropping my daughter into a lake, and I understood that this extreme fear was irrational. My patients who cannot let go of this level of anxiety are experiencing this all the time. I think there are moments in our lives when we brush up against the kinds of suffering that people endure. For me, that lends a greater capacity for empathy. And what strikes me in seeing my patients is how vulnerable all of us are to losing an equilibrium that we might otherwise have. A huge tragedy can rock your whole foundation.

Those diagnosed with body integrity identity disorder believe that a part of their body—a leg or a foot, for example—isn’t meant to be there, and they want it cut off. Which would, in fact, “cure” their condition and help them feel better. You write, “What is worse: to live without a leg or to live with an obsession that controls your life?”

These people are in touch with reality, it’s not as if there are strange voices to cut off their arm or pluck out an eye. They just feel, very much, that “my right leg doesn’t belong” or “I was meant to be an amputee—my left leg should end above my knee.” These are very precise ideas. The research demonstrates that if, in fact, they become amputees, which they sometimes do through very gruesome measures on their own, the suffering resolves. As doctors, we have taken an ethical oath to do no harm. So it’s difficult to square the idea of amputating a healthy limb as treatment for someone. But it can stop suffering. So that kind of question is exactly what falls into the category of the “mystery of psychiatry.” How do we begin to understand that feeling and the resolution of that feeling? If we have a means of resolving the distress, are we compelled to do it even though we don’t fully understand the etiology of the distress or the resolution? Are you cutting off a leg to treat an illness of the brain? It’s so difficult to comprehend, but we do all kinds of treatments that we don’t exactly know how they work but we know that it helps people get better. It’s a real dilemma that has more to do with repugnance and our response to the proposed action than anything else.

Do you see any implications here with gender reassignment surgery? Is gender dysphoria—the condition in which a person believes he or she was born the wrong sex—technically a psychiatric condition?

These are heated waters to wade into. It has, at various times, been classified as such. My suspicion is that increasingly, people understand the appropriateness of gender reassignment surgery and have seen enough of those cases and the positive results that can occur that we understand the plight of transgender people better than those with body identity integrity disorder.

One criticism often weighed at psychiatry is the idea of over-diagnosis. What do you think about this?

It’s both true and not true. There are people who are over-diagnosed and over-treated, but many, many patients need treatment. It depends a little on the population. Plenty of people point fingers towards the “worried well,” people who are on psychiatric medications that need not be. That may be a reality in that population. On the other hand, working in a psychiatric hospital, the reality I encounter far more often is people with significant mental illness who are not receiving the care they need.

Is it ever a class issue? Do more privileged classes get over-treated? Do less privileged groups fail to get treatment they need?

Suffering certainly does not discriminate. And mental illness doesn’t discriminate. There are all kinds of socio-economic groups that have members who are very ill, who are afflicted by every mental illness you could list. That said, there’s no question that people with fewer resources have less access to care. I see a lot of college students who experience their first psychotic break, and many of them come from affluent families. They are able to connect with and generate quite a lot of care because they’ve got good insurance, their families may know physicians they can call in the middle of the night for advice, they have the capacity to drive their kids to major medical centers where they may specialize in illnesses their children are facing. Those resources provide greater access to care. A homeless person has few resources and won’t be as able to make the connections needed, have transportation needed. I see so many patients for whom the $4 prescription charge for a month of medication at Wal-Mart is prohibitive.

And what’s at stake for those who aren’t treated?

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Hope Reese is a writer and editor based in Louisville, Kentucky. She writes for The Boston Globe, The Chicago Tribune, and The Paris Review. She also hosts a radio podcast for IdeaFestival. Her website is

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