Month: December 2020

The issue of over diagnosing in medicine has been a growing concern for many professionals in healthcare. The late Dr Lisa Schwartz, her husband Dr Steven Woloshin and Dr H. G. Welch in their book Over Diagnosed: Making People Sick in the Pursuit of Health (2011), warn of the emerging trend of over aggressive diagnosing in the medical field.

With advances in new technology there is a greatly increased ability to detect abnormalities in patients when undergoing investigations. Yet without fully understanding the clinical significance of these abnormalities the physician, fearful of being accused of negligence is more likely to make a diagnosis and later embark on unnecessary treatment. They question the impact that this trend may have on patients with milder symptoms and transient medical conditions.

The authors note: “While failing to make a diagnosis can result in lawsuits, there are no corresponding penalties for over diagnosis.”

They warn of an epidemic of diagnoses, where everyday experiences of physical or mental discomfort may become a diagnosis. This trend is seen especially in younger patients where sleep difficulties become insomnia, cough and breathlessness after exercise becomes asthma, a reading difficulty is dyslexia, restlessness and inattention is ADHD and unhappiness becomes a depressive disorder.

This issue is well exemplified by the results of a survey published in Ontario in 2019 which reported that 65% of college and university students stated experiencing overwhelming anxiety in the previous year and 46% complained of disabling depression.

One commentator has asked: “If everyday experiences are labelled in this manner, and more than half of us are sick, what does it mean to be normal?”

Mental Health: What is Normal?

So in terms of our mental health; what is normal? How do we define mental illness? Is a sociopath mentally ill?

Open a psychiatric textbook and you will read that mental illness refers to disorders of the mind that result in significant changes in a person’s thinking, emotions and/or behaviour and these disorders are classified into diagnostic categories. The two most important systems of these categories being the International Classification of Diseases (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

But what do these systems of categories really tell us? They provide us with a description of disorders neatly collected into tidy groups having in common shared symptoms. Examples being Major Depressive Disorder or Obsessive Compulsive Disorder. However these diagnoses tell us nothing about the complex biological, cultural or psychological human experiences in which these disorders are embedded.

Mental illness has been recognized throughout history in every society and has been known by many different names. Culture and ethnicity play an important role and influences how so-called abnormal behaviour is interpreted and understood. One culture’s abnormality is another’s cherished tradition.

Unlike medical illnesses such as pneumonia, where the diagnosis is decided by blood tests and X-rays, there are few objective laboratory tests for use in routine clinical practice in psychiatry. The making of a diagnosis of a disorder, is much more subjective and is biased in different ways by the rich complexity of human nature and the accepted mores of society at any given time.

And so to go back to our earlier question: Is a sociopath mentally ill? Well, in looking for an answer and we open the DSM-5 manual, we find that sociopathy is definitely catered for under the diagnosis of Antisocial Personality Disorder. Are we to conclude that the sociopath’s behaviour which can sometimes be criminal, be understood as a manifestation of a mental disorder which requires treatment rather than a jail sentence?

And more about this issue later!

Karl O’Sullivan MD

We hear a lot about depression these days and we are told that depression is experienced by increasing numbers of people. We read about it in the press and its increasing prevalence is widely reported on radio and on social media.

So what is happening? More and more people, especially the young complain that depression has become a feature in their emotional lives. Yet those of us who live in economically advanced countries have never had it so good in terms of our standard of living and general material benefits. To quote: western society has never been so prosperous, yet western society has never been so depressed!

So what is going on? Do we have an explanation for this paradox? Are we really becoming more susceptible to depression or as some experts have suggested, depression has become modern society’s label for unhappiness.

Perhaps it is an indication of an emerging perspective that bad things are not supposed to happen to us, and when bad things do occur, they are perceived as an abnormal intrusion into our lives and are relegated to the domain of pathology or disease. So rather than acquiring the skills to deal with an adverse experience ourselves, we seek help from the expert whom we expect to problem solve our difficulties and often with the assistance of pills.

This issue is especially relevant today with reports of rising rates of mental illness in our communities and particularly in young people.

A 2018 study published by Higher Education Research at the University of California, Los Angelas reported a consistent rise in anxiety in first year university students over a period of thirty years. For example in 1985, 18% reported overwhelming anxiety, this figure rose to 29% in 2010 and to 41% in 2017.

Another example; in 2019 the Ontario University and College Health Association reported the results of a survey completed in 2016. It revealed that 65% of students described experiencing overwhelming anxiety in the previous year while 46% stated that they experienced depression sufficiently severe that “they found it difficult to function“.

While closer to home here in Oakville, the emergency department of Halton Healthcare Services saw an increase in patients (of all ages) presenting with a major psychiatric diagnosis rising from 3,392 in 2009 to 12,333 in 2019. This trend was also seen in other hospitals in Ontario.

What does this mean? Is mental illness really on the rise? Are we as a society more susceptible to mental illness? Are we becoming more sychologically fragile, especially our youth?

The emerging influence of social media in society has been noted by many as one of the most significant social changes over the past twenty years. It has been further noted that the impact of these changes may have had a detrimental affect on the lives of young people.

For example, smart phones became available in 2007 and it is reported that by 2015 almost ninety percent of teenagers owned a smart phone. This increase in their availability coincided with a sharp spike in the number of young people seeking help for psychological issues. Problems identified included, low self esteem, sleep deprivation, social isolation with loss of social skills, and multitasking, resulting in ADHD type behaviour. Body image issues were a concern in younger women when they compare themselves to the idealized images they often saw on social media.

A paper published in the Canadian Medical Association Journal in 2020 raised the interesting point that what we are seeing are rising rates of psychological distress rather than strictly diagnosed psychiatric disorder. Other experts have noted, for example that prevalence rates for schizophrenia have not increased in recent decades.

Yet psychiatric illnesses that we consider culturally sensitive are making increasing demands on the health services and these include eating disorders, ADHD, addictions, autism spectrum disorder and post traumatic stress disorder.

Are we observing a true rise in mental illness or does this reflect a trend that we are becoming more expansive in our diagnostic habits? This trend has been described by social psychologist Professor Alex Haslam as “creeping clinicalism” or “concept creep” where concept boundaries are progressively stretched, and we run the risk of pathologizing behaviour that may be more a manifestation of temporary distress rather than an indication of the presence of a serious mental illness.

And more about this issue later!

Karl O’Sullivan MD