Dr Ghaemi Responds

A critical book review is never pleasant, for author or reviewer, yet because ideas have consequences, such debates are unavoidable. In his book, the author claims that “bipolar disorder should be a diagnosis of exclusion, and made only after other, lesser, diagnoses fail to account for a patient’s thinking, feeling, and behavior” (page 53). This contrasts with the traditional meaning of diagnosis of exclusion in which one needs to rule out more serious illness (not lesser ones) before making simple diagnoses. Thus, we rule out pneumonia before the common cold, and we should rule out bipolar disorder before invoking mere personality traits. In the case of supposed misdiagnosis of schizophrenia (Chapter 5), Dr Muller describes 3 years of personal contact without making it clear to me, at least, even on a second reading, whether he is the person’s psychotherapist or his friend. In either case, the author makes numerous personality disorder diagnoses instead.

Regarding David Healy’s recent book, readers can follow my comments on his critique elsewhere.⁵ I take issue with Healy’s interpretation of psychiatric history. No pharmaceutical companies existed in Paris circa 1854 when bipolar disorder was first described in the modern era much as it is now, not to mention ancient Roman descriptions that parallel current concepts of the bipolar spectrum. On perhaps the key topic that motivates the author, I agree that meaning is important in psychiatry, but there are many perils (including overdiagnosis of personality disorders) in understanding meaning appropriately. The dogma of treating everything as having meaning is not an advance on the dogma of treating everything as meaningless. The truth is more complex than simply taking a position opposite to what is “wrong.”

S. Nassir Ghaemi MD MPH

Boston