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

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 probably 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...