1 Boring Old Man

After the DSM-III was introduced, people facile with its contents began to "talk funny" [I can’t think of another way to say that]. First, there was a high premium on being able to talk in DSM-ese – using diagnostic terms wherever possible. So instead of "he’s very depressed" they would say "my diagnosis is Major Depression without Psychotic Features." That wasn’t so bad, but there was more. "He has a Major Depressive Disorder and comorbid Generalized Anxiety Disorder" [some would actually say, "MDD with comorbid GAD"]. What that meant was that the depressed person was really anxious. I learned to listen to people talk that way without flinching, because I realized that they were being taught to speak as if these diagnostic categories were nouns, rather than … [I don’t know how to finish that sentence – adjectives or adverbs, maybe]. But comorbid still gets to me, particularly when it’s said with earnestness and emphasis – implying some special meaning. One place it’s tricky is when KOLs use it to suggest reasons to prescribe more medicines – like when they talk about Major Depression being comorbid with medical illness, often implying that depression causes or worsens physical illnesses. Not much science there, particularly since there’s no solid evidence that antidepressants are much help in those situations.  But beside that, there’s something wrong with Major Depression being comorbid with medical illness anyway. It pathologizes being human. It’s depressing to be sick, particularly to be real sick.

 

^{‘PSYCHIATRIC COMORBIDITY’ AND THE NATURE OF PSYCHOPATHOLOGY}

^{Most of the recent debate about psychiatric comorbidity has been remarkably atheoretical, focusing on the practical usefulness of one or the other approach in terms of treatment selection and prediction of outcome and service utilisation. However, the emergence of the phenomenon of ‘psychiatric comorbidity’ has obvious theoretical implications. The frequent co-occurrence of the mental disorders included in current diagnostic systems has recently been regarded as evidence against the idea that these disorders represent discrete disease entities. The point has been made that the nature of psychopathology is intrinsically composite and changeable, and that what is currently conceptualised as the co-occurrence of multiple disorders could be better reformulated as the complexity of many psychiatric conditions (with increasing complexity being an obvious predictor of greater severity, disability and service utilisation). From the psychodynamic viewpoint, the idea seems to be reinforced that the interaction of congenital predisposition, individual experiences and the type and success of defence mechanisms employed may generate an infinite variety of combinations of symptoms and signs. From the psychobiological viewpoint, the hypothesis seems to be supported that ‘noxious stimuli . . . perturb a variety of neuronal circuits . . .The extent to which the various neuronal circuits will be involved varies individually, and consequently psychiatric conditions will lack symptomatic consistency and predictability’. From the evolutionary viewpoint, the concept seems to be corroborated that mental disorders are the expression of preformed response patterns shared by all humans, which may be activated simultaneously or successively in the same individual by noxae of various nature – a view endorsed by Kraepelin himself in one of his later works, in which he dismissed the model of discrete disease entities even for dementia praecox and manic–depressive insanity.}

^{However, the emergence of the phenomenon of ‘psychiatric comorbidity’ does not necessarily contradict the idea that psychopathology consists of discrete disease entities. An alternative possibility is that psychopathology does consist of discrete entities, but these entities are not appropriately reflected by current diagnostic categories. If this is the case, then current clinical research on ‘psychiatric comorbidity’ may be helpful in the search for ‘true’ disease entities, contributing in the long term to a rearrangement of present classifications, which may involve a simplification (i.e. a single disease entity may underlie the apparent ‘comorbidity’ of several disorders), a further complication (i.e. different disease entities may correspond to different ‘comorbidity’ patterns) or possibly a simplification in some areas of classification and a further complication in other areas.}

^{There is, however, a third possibility: that the nature of psychopathology is intrinsically heterogeneous, consisting partly of true disease entities and partly of maladaptive response patterns. This is what Jaspers (1913) actually suggested when he distinguished between ‘true diseases’ (such as general paresis), which have clear boundaries among themselves and with normality; ‘circles’ (such as manic–depressive insanity and schizophrenia), which have clear boundaries with normality but not among themselves; and ‘types’ (such as neuroses and abnormal personalities), which do not have clear boundaries either among themselves or with normality. Recently, it has been pointed out that throughout medicine there are diseases arising from a defect in the body’s machinery and diseases arising from a dysregulation of defences. If this is true also for mental disorders – for example, if a condition such as bipolar disorder is a disease arising from a defect in the brain machinery, whereas conditions such as anxiety disorders, or part of them, arise from a dysregulation of defences – then different classification strategies may be needed for the various areas of psychopathology.}

Dr. Maj is an internationally renown psychiatrist from Naples Italy who is on the Mood Disorders workgroup for the DSM-V. He is President of the World Psychiatric Association. He has been President of the European Psychiatric Association (2003-2004) and of the Italian Psychiatric Association (2000-2002). He is member of the Italian High Council of Medicine. He’s the author of many books, one entitled Psychiatry as a Neuroscience. But no matter his orientation, he’s a clear thinker, and put his finger on the problems of our diagnostic classification for me – insoluable problems in its current form. It misses the "gestalt" of the conditions we think of as diseases, and it omits the possibility that I think is actually a simple truth at the level of "we hold these truths to be self evident:" "…the nature of psychopathology is intrinsically heterogeneous, consisting partly of true disease entities and partly of maladaptive response patterns."