Learning to be a psychiatrist means learning the names of a lot of disorders. Without these names, what would we have? A welter of distress, a confusion of symptoms. It would be very hard to say to a colleague, when pressed for time, what was wrong with any particular patient: “Well, his mood is low every morning, he doesn’t eat, his sleep is poor, his wife says he’s lazy and neglecting their child” might only be the start. But if you say, “He has an episode of moderate to severe depression, not responding to an SSRI”, your average psychiatrist has a grasp of the problem and what they might need to do.
The problem is that the disorder, or the diagnosis, is attached to a standard group of symptoms and signs, which is fine if your patient fits them all neatly, but can be a problem if they don’t. As psychiatrists, we are so familiar with these disorders that we may doubt a patient’s story if they deviate from the pattern. We might think, for example, that someone can’t be hearing the voices they say they hear because it doesn’t fit with the rest of their presentation. We want patients to have the symptoms we expect, and that we may be able to cure.
This is understandable, but flawed, and when you are a psychiatrist who’s also a patient, it can become hard to navigate. I learned about psychiatry from an external position of reading books, seeing patients and listening to those far more knowledgeable than I am. I experienced psychiatry in a state of fluctuating despair, with feelings of anger and self-loathing. From the outside, maybe I looked like a classic patient with depression, but that simply wasn’t what it felt like. I was the same person I had always been, but everything seemed different, and I couldn’t make any sense of it. I still can’t, and it’s this unpredictability that’s so frightening. I don’t get a sore throat or a rash that I can see and think, “Ah yes, I’m getting ill.” I just can’t see the world, or myself, in the same way.
Psychiatry is, to an extent, subjective and some people will be diagnosed with different disorders by different psychiatrists at different times. This is a very difficult area. As a psychiatrist you have to do the absolute best you can, and if you disagree with the previous psychiatrist, then you need to say so. It will have implications for both prognosis and treatment. But think what it’s like for the patient – you have a diagnosis that you may or may not like, but you start to accept it. Then someone comes along and says, “No, that’s wrong.” As a patient, a diagnosis can be vital in providing some kind of validation, and it also gives a recognised way of communicating what is wrong to other people. This can be very necessary, both on a personal level and also for issues such as work and benefits.
I have had my diagnosis changed a few times: from depression to bipolar disorder, back to depression and bipolar disorder again. I still find either hard to believe, and I think the changes have contributed to this. When I started writing and speaking more about being a patient, I asked my psychiatrist if he was going to change it again, at least partly because I felt I would lack credibility if this happened. He assures me he won’t, but the fact that it’s happened already means I can never fully believe him. I do believe I have some form of mental illness, but I’m still not sure it fits neatly into a box.
So when I morph back into a psychiatrist, how can I marry the need to make diagnoses with my lack of personal commitment to them? I’m not sure I can. But I can try to accept that there are many things I won’t understand fully, and perhaps my own mental illness is one of these. I don’t think about all this when I talk to patients. You have to be able to step back a little when you’re someone’s doctor, although I do like to think it makes me kinder. And while I don’t have a rigid belief in the array of psychiatric disorders I’ve learned about, I do think that they give a much needed structure, in which we can look for patterns and commonalities. This may at times appear to strip the individual of their distinctive story, but perhaps that needs to happen sometimes in order to see the wood from the trees. The caveat there being that it’s really important never to forget about the trees, because therein lies the person.
As humans, we like to give names to many things, starting with ourselves and the people around us, and increasingly to explain how we see the world. It can be hard when the name appears to become the thing to even remember that it’s just a word. Depression and melancholy are inextricably linked to sorrow; yet, for me and perhaps others, this is not really how it feels. I wouldn’t call myself sad when I’m depressed, I’m more disgusted by myself and devoid of energy.
So I will remember the names of these disorders and I will continue to use them, but I will remember that they are likely to change over time. This does not necessarily matter, and may reflect new thoughts, new concepts and, hopefully, new treatments. I will also remember the importance of these words for patients, and that they should not be lightly used. There are many words in the field of mental illness that have been discarded and are now viewed as stigmatising and inappropriate – words such as “cretin”, or “lunatic”, or “mental”. It’s interesting to consider whether our current crop of acceptable words will end up in that category, and it’s salutary to know that many probably will.