Sunday, December 15, 2013

In Whom Does Mental Illness Reside?

Note: All patient stories have potentially identifying details changed to protect privacy, and composites of multiple patients may be used.

Dara was a teenage girl prone to outbursts, mainly at home. Her parents have been divorced for many years, and she mostly lived with her mother, a well-heeled professional. Every single week presented another crisis. Dara would refuse to go to school if she did not get up on time. She would push or hit her younger sister Lisa for no apparent reason. She would get so mad at her mother that she would write "I hate you" on the side of their house in permanent marker. Her mother made an appointment for her after discovering that she had written in her diary that she wished she were dead.

When I met individually with Dara and asked her about these outbursts, she was always quick to blame Lisa for provoking her or her mother for being mean to her. She told me about how she feels her mother always favored her sister over her. She could not tell me one thing that she enjoyed doing with her mother, and she felt that her mother has never liked her. With her mother and sister, she was irritable, easily upset. However, when she was with her father or her friends, she was usually cheerful, and that was how she appeared to me during most of our visits. She has never been depressed most of the time for more than a day, and she explained that she wrote that she wished she were dead after an argument with her mother, but she has never thought about killing herself. She has never had any grandiosity, elevated mood lasting more than a few hours, or decreased need for sleep, although she stayed up late reading Harry Potter.

Dara's mother always showed up to our appointments with a stoic, unchanging expression. Over the course of several visits, I tried to find out more about her relationship with her daughter. I eventually learned that she had grown up with a mother who had an explosive temper and was verbally and physically abusive. She has not visited her mother in years, and it appears that she learned to control (or suppress?) her feelings without ever letting them out like her mother did. Dara's mother readily admitted that her daughter reminded her a lot of her own mother; she has felt this way ever since Dara was a colicky infant whose cries kept her awake most of the night for months.

When I asked Dara's mother what she thought was going on with Dara, she told me matter-of-factly: "I believe that my daughter has a mental illness, and that she needs help. I think she might have bipolar disorder, and she should be on a medication for her mood swings."

I did not end up prescribing Dara any medication besides recommending melatonin to help her sleep earlier. I tried to work with Dara and her mother on understanding each other better and de-escalating their conflict. Dara's outbursts gradually decreased in frequency, though I got the sense that both moter and daughter were still walking on eggshells. I began talking with them about seeing a family systems therapist, and neither one warmed up to the idea. After a few months, they stopped following up with me, and I do not know if Dara eventually ended up being put on medications.

So is Dara really mentally ill? Or do both mother and daughter have a mental illness? Would the issue best be characterized as a behavioral problem instead? Or a parent-child relational problem?

I had been thinking about this patient story for months now, but what finally motivated me to write about it was Dinah's recent post over at Shrink Rap in which she shared:
I'm a psychiatrist, and I confess, I have no idea who these "mentally ill" are.  I think if you asked many people in treatment about being mentally ill, they might think you are talking about someone else.  People may not think the term applies to them because they don't have the insight to realize they are sick.  Or, they may not think of themselves as mentally ill because with treatment, they've gotten better. […] It might not occur to a patient to identify themselves as "the mentally ill" even if they take medicine and go to therapy.
When I tried to take her poll on "Who are the Mentally Ill," I realized that I wanted to say "False" to most of the questions (e.g. "Anyone who takes a psychiatric drug prescribed a by primary care doctor is mentally ill"), but I could not fully explain to myself why or how I reached that conclusion. However, I gained some much-needed clarity from reading Dr. Steven Reidbord's very thoughtful post, which concluded:
Since "mentally ill" obscures as much as it clarifies, perhaps no one should be labeled this way.  Indeed, only in psychiatry can a person be declared ill by someone else.  In the rest of medicine, it’s self-descriptive.   In my view, "the mentally ill" harbors too many unstated implications and vaguely shared assumptions regarding whom we are talking about.  Legal restrictions and entitlements should be based on more concrete standards — and actually, they are.  "Mental illness" is more of a rhetorical flourish, a bit of hand-waving when it’s difficult or inconvenient to pin down specifics.
Dr. Reidbord articulated what I long felt, which is a discomfort with the term "mental illness." Thinking back on my own interactions with my patients, I cannot recall ever telling a patient that she has a mental illness. It's just not useful from a clinical perspective.