Leaving Psychiatry. J. R. Ó’Braonáin. M.D.
the parents were perfectly adequate, did their best and the child simply had the misfortune to be born with an insecure temperament or was not insulated enough from media that makes a mockery of parental authority, basic morality and dismantles any message promoting self-control. Life neither guarantees perfect parents or perfect children. In any case, there is something to be lacking in the psyche of the young lady of our example (or young man also), some emptiness looking to be filled. And sometimes it will be filled in its turn. Perhaps a new love or hope or love will enter the scene, as the patient reaches out in irresponsible and often dangerous ways. There is no medication as powerful as infatuation. This will be a time of “high”. Perhaps the “high” follows from simply boredom with being down in the dumps and loathing of the self, the psyche finding time in prison served and time now to throw off the shackles of the superego enough for a little happiness and gay abandon (there’s the “hypomania”). Yet the good times do not last long before doubts and self sabotage creep in. Then back we are in a morass of unhappiness and angst. Or she meets the love interest, soon feels comfortable, then just as soon doubts creep in, acting dramatically as if to hurt the other and force them to prove their love is unconditional, a comfort left wanting from the absent bosom that was her childhood. The object of her affections might weather the storm and his/her apparent reciprocation of love (or lust) might persist long enough for our insecure patient to feel comfortable again. Yet this sense of comfort is not to endure for long. And so the sadomasochistic like cycle repeats, often with some quasi sadomasochism from the love interest, for they often have their own psychological issues. When things go well there might be promiscuity and intemperance of all kind, including mood altering substances, the use of which may or may not be confessed and which certainly causatively upsets the psychological apple cart all the more. When things go poorly the mood will be lower, with or without thoughts of self harm. The reader will note this is the same patient as the first, with identical boxes checked. Only in the latter case with a different psychiatrist she is diagnosed instead with borderline personality disorder (DSM), otherwise known as emotionally unstable personality disorder (ICD).
Both diagnoses, i.e. type II bipolar disorder vs borderline personality cannot be simultaneously correct, for they rest upon entirely different theoretical substructures of aetiology and “pathogenesis”, though there is a growing vanguard of psychiatrists incoherently attempting to meld them as one “bipolar spectrum”. Regarding my own experience, I’d be on safer rhetorical ground to say something like “most patients I have seen fit much better the latter formulation”, i.e. borderline personality disorder, in so doing appearing to be a little more conciliatory, a little less extreme. Yet the truth is that after having seen literally hundreds of (usually female) patients diagnosed as type II bipolar by (usually private practicing) psychiatrists, I have yet to see a single one who is not personality disordered as a crystal clear complete explanation of the case. Not a single one!
I have even seen many dozens of patients falsely diagnosed by many a psychiatrist with the full enchilada of type I bipolar disorder, i.e. that subtype of bipolar disorder (manic depression), where the upward swing of mood renders the person insane and needing hospital admission or urgent intervention, i.e. a full mania. Or so the diagnostic criteria in the bible (sorry DSM 5) would require of me to make the diagnosis. One recent case of many comes to mind where it was uncanny how the mania always occurred when the husband was cheating on his wife, sexting his mistress dozens of times a night and driving recklessly enough to attract the ire of the police. It was truly remarkable how his mania, or depression, would switch off the moment his wife forgave him or the psychiatrist arranged a letter of support for his crime of reckless driving, absolving him of his sins. I guess one could marvel at the power of love and compassion or advocacy or “stress” have been taken off his shoulders. I would marvel at the mendacity on the part of the patient, and fraud (or stupidity) on the part of the psychiatrist.
Or there are the cases where, as a trainee, the patient would sit across from both myself and the supervising psychiatrist, the patient narrating with modulated (non manic) speech and tempo of thought how their “bipolar was acting up”. And so there lay the attribution for the hefty bill received by the credit card company when they spent too much. The psychiatrist would agree their bipolar made them do it. If push came to shove the debt would climb and the psychiatrist would write a support letter in an attempt to absolve the person of their debt, or an application for state (i.e. tax payer funded) assistance with an invalid pension. Some would call this compassion and patient advocacy. Some might also call this fraud.
I ask the reader to forestall from concluding that I don’t believe bipolar disorder exists at all. Putting aside for now the far more interesting question of what it is for any psychiatric diagnosis to “exist”, I’ve been convinced of about a few dozen cases of type I bipolar disorder over the years, where to be “convinced” means a certain level of comfort with applying the construct of type I bipolar disorder to the patient, not to be convinced of any greater ontological truths about the construct itself as a brain disease. These few dozen patients are extremely low numbers as a proportion of population, far below the rate at which a sizable fraction of contemporary psychiatrists diagnose bipolar disorder and far below what the guild intelligentsia state is its prevalence (i.e. its commonality in the community).
But enough of digressions from the point, for these examples are mere illustrations. The point for now is not what “exists” of bipolarity in the world (for this is but an example), but what “exists” in psychiatry in the world, what psychiatry can claim to know, and what psychiatry does. Plenty of my colleagues are uncritical true believers in type II bipolar disorder and see hypomania (if not mania) and mixed mood episodes everywhere they look. And plenty of my colleagues conversely also cast a jaundiced eye on the construct that is type II bipolar disorder and the supposed commonality of type I bipolar disorder. In conversations with colleagues, some of those disbelievers privately admit to using the diagnosis as something to work with, as a pragmatic metaphor to offer the patient who is looking for the comfort of a label, without disclosing to the patient that they lack the faith in the diagnosis themselves. It follows that the patients are not always fully complicit with this benevolent little white lie (actually another fraud), whilst the practitioner is wantonly ignorant of the fact that diagnoses have consequences, these rippling far and wide beyond the immediate comfort of the label to the patient. When I have been bold enough to challenge patients on what they call their “bipolar acting up” when it is obviously their characterological deficiencies acting out, I often get more of an inkling they know the truth beyond the lie, and so their previous psychiatrists (if they are not the more common true believer) have been lying to them and vice versa.
Were the construct of type II bipolar disorder ever to be revealed or discovered to be the fiction that it is, I have no doubt mainstream psychiatry would dodge embarrassment by rewriting its own history, with unanimous claim that the expert class as a whole knew the truth all along, with a couple scapegoats thrown under the bus along the way and only ever if absolutely necessary. Overdiagnosis by psychologists and family/general practitioners will do as a nice scapegoat. The guilds of psychiatric story-tellers are as skilled at managing historiography as they are lacking skill at managing what was once called hysteria. Yet from a patient’s perspective, never will you see a jaundiced eyed psychiatrist tell a patient the colleague who previously made the diagnosis was just plain wrong or likely lying. A diplomatic psychiatrist seeking to revise a diagnosis might go so far as to say something akin to diagnoses being a work in progress evolving over time, which is actually to say the truth can be x yesterday, y today, and z tomorrow, a convenient timelessness where there is no “now” in which to capture and indict the psychiatrist as being wrong or mendacious. This is like Parmenides by the river into which he can never step twice. Nothing ever is the case and everything always is the case in such a state of flux where a diagnosis is never allowed solidify. Conflicts over diagnostic constructs or applications of these to individuals never ever see our secular priests defrocked or schisms within our secular church, unless the church is absolutely forced to. Internal dissent within the guilds is castrated of any real gravitas in the first instance, and smooth on the surface to all outside observers. As several psychiatrists have said to me, the greatest imperative is “we must not bring the profession into disrepute”. Why not? This is a question they never ask never ask and the answer is never provided, for protecting the profession is axiomatic. It is canon.
So