Context Does Not Determine “Disorderness” or Normality

In part 1 of this essay, I argued that panic attacks are nearly always pathological and disordered states, even when they occur in an understandable context. I also distinguished the maladaptive aspects of panic attacks from the adaptive nature of the classic fight or flight response, sometimes known as the general adaptation syndrome. Indeed, because panic attacks per se appear predictive of subsequent psychopathology, one proposal for DSM-5 is to rate panic attacks as a separate dimension of pathology, across all mental disorders.

But the issue of context and its relationship to disorderness extends well beyond panic attacks: it arises in nearly all psychiatric diagnoses not explicitly defined contextually. Some DSM disorders, of course, are context-bound by definition (eg, PTSD requires a trauma, adjustment disorders require some precipitating psychosocial stressor). For most other DSM diagnoses, however, the basic question arises: if we can understand the patient’s presenting signs and symptoms, owing to an explanatory psychosocial or environmental context, are we entitled to regard the patient’s condition as normal, non-pathological, or non-disordered?

I would like to suggest that such an explanatory context does not remove a psychiatric condition’s pathology-or the need for treatment-once the condition crosses a certain threshold of suffering and incapacity. Context does not dissolve disorder, even if it seems to explain it. And often, we are quite wrong about such seeming explanations.²

Indeed, if someone who climbed mountains for a living repeatedly and frequently experienced panic attacks whenever standing on the edge of a cliff-resulting in prolonged or pronounced suffering and incapacity-this state of affairs would be the dysfunctional equivalent of disease. On this view, pathological states are constituted by pronounced or prolonged suffering and incapacity-or, if we prefer, by profound distress and disability. While the term “disease” resists an essential definition-ie, one specified by necessary and sufficient criteria-most “disease” conditions have pronounced or prolonged suffering and incapacity in common. These features constitute what the philosopher Wittgenstein³ termed “family resemblances” and may be compared to the overlapping fibers that make up a rope.

To be sure, not all pathological or disordered states constitute clinical disease. In our ordinary language, we usually don’t apply the term “disease” to states of suffering and incapacity that are related to a visible wound or injury, such as a knife wound. Nor do we usually apply the term “disease” to suffering and incapacity that is inflicted upon someone by external malefactors, such as terrorists or kidnappers. So, in this very limited sense, context does play some role in how we use the term “disease” in our ordinary language.

There is another sense in which context plays a limited role in how we assess the disorderness of a condition. When a person experiences intense or prolonged suffering and incapacity “out of the blue”-ie, in the absence of any known psychosocial precipitant or other explanatory context-our clinical suspicions are usually raised. We suspect some kind of internal disease process at work, such as a covert malignancy; or, in the case of major depressive symptoms, we suspect what used to be called an “endogenous” depression. In this limited sense, then, the contextualists are correct.

Where contextualists err is in supposing that the presence of an understandable, explanatory context-such as recent bereavement, job loss, or hanging off a cliff-somehow renders a condition normal, non-pathological, or non-disordered, all other things being equal. Curiously, this fallacious reasoning seems more common in psychiatry than in general medicine. Consider the patient who after abdominal surgery develops clinically significant pain at the incision site. The pain-while entirely understandable and perhaps even statistically common-is nevertheless considered pathological and is quickly treated by diligent clinicians. The patient in such pain is suffering and is probably incapacitated.

What about the biological context of a person’s psychiatric symptoms? To be sure, the biological context affects our diagnostic formulation, but not the disorderness of a person’s clinical signs and symptoms. The person running down the street naked while screaming and breaking car windows is in a pathologically disordered state, whether the context is recent cocaine intoxication, florid mania, or a terrible and understandable psychic trauma. To be sure: we need to pursue that differential diagnosis. But our ability or inability to understand the genesis of the person’s behavior is irrelevant to our determining that the condition is pathological and disordered. Regardless of context, once a certain threshold of suffering and incapacity is crossed, physicians justifiably apply the term “disease” (or “disorder”) to the person’s condition. (For purposes of this discussion, I am using the terms “disease” and “disorder” more or less synonymously, although the medical literature is remarkably inconsistent in how these terms are applied.⁴)

This is also true of maladaptive symptoms attributed to the patient’s developmental context.⁵ It is of course true that temper tantrums in a 2-year-old-or moodiness and impulsivity in an adolescent-are very often developmentally normal. But once a certain threshold of suffering and incapacity is crossed, we rightly impute disorderness to the child’s condition, make a diagnosis, and offer appropriate treatment. That the child’s symptoms occur in an understandable context does not render our diagnosis a “false positive.” Context helps explain pathology-it does not annul it.

Suffering and incapacity
Finally, since I have highlighted the criteria of suffering and incapacity, how do we assess and quantify these features? And isn’t any determination of this sort inherently subjective? Indeed, I believe we have only limited tools for assessing suffering and incapacity, and often these instruments are fairly crude. We do have objective, validated scales that help quantify the severity of specific symptoms or mood states (eg, the Beck Depression Inventory, the Hamilton Depression Rating Scale). The Global Assessment of Function scale, used in DSM-IV, provides a reasonably good approach to assessing a patient’s level of impairment and dysfunction. Similarly, the 15-item Patient Health Questionnaire (PHQ)-a brief, self-administered questionnaire-seems to be useful in assessing somatic symptom severity, which is correlated with the patient’s functional status.⁶

But it is harder to find assessment tools that get at the “inner world” of the patient, in the sense that phenomenologists emphasize-tools that would help us appreciate not only incapacity and somatic pain, but existential suffering in a broader sense. To do so, I believe we need to move well beyond the symptom checklists of the DSMs.⁷ In my view, the first duty of all physicians is to relieve pronounced or prolonged suffering and incapacity. We must do so, regardless of how understandable the context in which this experience arises. This does not mean “medicalizing normality”-it means doing what caring physicians have done for countless centuries.

Acknowledgments-My sincere appreciation to Dr Richard Maddock and Dr Sidney Zisook for their helpful comments and suggestions on early drafts or portions of this essay.


 

References:

References1. Batelaan NM, Rhebergen D, de Graaf R, et al. Panic attacks as a dimension of psychopathology: evidence for associations with onset and course of mental disorders and level of functioning. J Clin Psychiatry. 2012;73:1195-1202.
2. Pies RW. Depression and the pitfalls of causality: implications for DSM-V. J Affect Disord. 2009;116:1-3.
3. Wittgenstein L. The Blue and the Brown Books. New York: Harper Torchbooks; 1965.
4. Pies R. Moving beyond the “myth” of mental illness. In: Schaler JA, ed. Szasz Under Fire. Chicago: Open Court Publishers; 2004:327-353.
5. Wakefield JC, First MB. Placing symptoms in context: the role of contextual criteria in reducing false positives in Diagnostic and Statistical Manual of Mental Disorders diagnoses. Compr Psychiatry. 2012;53:130-139.
6. Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64:258-266.
7. Pies RW. After bereavement, is it “normal grief” or major depression? February 21, 2012. http://www.psychiatrictimes.com/blogs/dsm-5/after-bereavement-it-%E2%80%9Cnormal-grief%E2%80%9D-or-major-depression. Accessed January 4, 2013.