Aren't we all somewhere on the spectrum of disease? | Hacker News Reader

Aren't we all somewhere on the spectrum of disease?

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61 pointsscripthacker60 comments

This is a really dangerous and misleading way to look at bipolar.

The disease proper of bipolar disorder is progressive and degenerative. This progression is accompanied by structural changes in the brain [1] as well as biological changes in the body [2].

If someone had the syndromes of manic or depressed symptoms in response to a medication, that does not prove either way that the person actually has the progressive and degenerative disease that can induce those syndromes spontaneously. If withdrawing the medication completely solves the problem, it simply indicates that they don't have the disease.

The sentiment of "we're all a little crazy" is very old, and very dangerous to go around repeating. There's a specific threshold where things suddenly get orders of magnitude more fucked up, and anyone who has crossed this threshold will know how damaging it is to treat these diseases as if they're just an extension of normal human experiences.

If you have this disease, you need to halt the degenerative process. I've taken my meds every single day for the last 14 years because I know what will happen if I stop. I have friends and family that went down that road, and it isn't pretty.

[1] https://www.sciencedirect.com/science/article/abs/pii/S00063... [2] https://www.sciencedaily.com/releases/2016/05/160531104421.h...

> The disease proper of bipolar disorder is progressive and degenerative.

This is also not entirely true. It may spontaneously resolve itself in many cases[0]. I suspect that we've grouped a number of different disorders under the label "bipolar" because they all manifest with similar symptoms.

[0] https://www.sciencedaily.com/releases/2009/09/090929141530.h...

Thank you for that! I hadn't seen it before.

I'm a little nervous about the idea of coming to conclusions about individual outcomes based on national surveys of self-reported diagnoses. It seems like there are vast opportunities for outside factors to mislead attempts at analysis.

For example, the proportion of people who were misdiagnosed to start with; the increased openness over time when it comes to accepting or speaking about the diagnosis; the improvement in mental health resources meaning more diagnoses; the possibility that patients decompensate and lose insight or reject diagnoses over time; etc etc.

If you're thinking "that sounds like a No True Scotsman", you're right. The disease is clearly progressive for some people. Declaring that people who don't demonstrate that progression don't have the disease is semantically useless but may be clinically useful.

I think a large part of the problem lies in the difficulty of accurate diagnosis, coupled with people's personal experiences with misdiagnosis.

I've been misdiagnosed as bipolar in the past, and the medication regime I was put on lead to schizoid delusions and incredibly unstable emotional state that only resolved once I stopped taking the medication (under the monitoring of the psychiatrist who initially prescribed them).

My mother was also misdiagnosed as bipolar, leading to her actual condition of Borderline Personality Disorder going untreated until she attempted suicide (she died 6 months after because of complications relating to the attempt).

A friend of mine who is schizophrenic was also misdiagnosed as bipolar, because his delusions and paranoia were fairly minimal. In his case, the misdiagnosis was probably more helpful than not, as the medications were helpful in stabilising his mood.

My point here isn't that the medical establishment is bad or that doctors are stupid. It's that disorders related to mental illness are very, very difficult to diagnose and treat, even for incredibly intelligent trained professionals. Many disorders have significant overlap with other disorders. An effect whose impact is only made worse by the fact that a bunch of these disorders are highly co-morbid. Mix in the fact that the borders between healthy and unhealthy are not especially well defined, and it's easy to see where a lot of the contention comes from

I'll add that someone who might be (self-)destructively bipolar in one environment, might be able to 'manage' in another, even without medication.

I've had multiple friends with diagnosed bipolar disorder, and harrowing and heartbreaking stories of how this affected their lives well into their twenties or even early thirties.

All of them have found ways to 'manage' their condition, without medication, through a combination of lifestyle changes, (odd) environments, and, perhaps most importantly, a group of friends who can deal with it or provide support in various ways. Some of them have been on medication for periods, and much prefer their current, imperfect situation.

By no means would I advocate avoiding medication, and I'm absolutely not saying that this can work for everyone. I'm also not arguing that their lives are just peachy now. It's a serious disorder.

And I do agree that people making statements like "we're all a little bipolar/autistic/borderline/etc." are often not helping and often actively harming those who are any of that more than 'a little'.

I've been diagnosed with autism and it's maddening how often, when I open up about it, people will say stuff like "well isn't that 'just' <x>" or "everyone has that". At this point I usually don't even bother trying to explain that there's a difference between, say, being punctual and curmudgeonly about it, and having a borderline-meltdown when plans change.

This is very interesting. I had a childhood diagnoses that I've always chalked up to just imitating my properly diagnosed single-mother. I was also under the impression that if I truly had the disease, that my current level of mood stability would be impossible.

Though my years don't line up with the results of the study at all. I was medicated from 8-14, and then really mellowed out around 19.

There are also structural changes in the brain as time passes, and hopefully biological ones as well if I'm going to digest this food I just ate. What structural changes are present and can these changes be used to diagnose the condition? Are these changes necessary for the condition? To me it looks like gray matter loss is not exclusive to this condition, these studies only quantify brain matter density, not structure. This study is also not very well designed, it only studies BPD patients without studying patients that may potentially have the identified defect but not the diagnosis.

Our diagnosis of psychological conditions is very vague as well--is bipolar disorder diagnosed as lack of gray matter? If it's not, then why not?

I'm pretty sure there is more extensive literature involving the exact types of degradation that is characteristic to the disease, but I do not think I'm competent to cite it correctly.

I'd imagine this process isn't so great for diagnosis given that it's mostly been observed in people with decades of uncontrolled disease behind them.

I've definitely crossed that threshold before and, personally, I feel like I could have been better served by practitioners who viewed my condition as more of a place on a spectrum than as a specific disease that could be treated with medication. I tried many prescription drugs (or many were tried on me), some which had disastrous side effects. I had the best response to lithium which I used for a few years but it made me balloon up in weight and had some other negative side effects. For about 12 years I've managed my position on the spectrum with a combination of diet, introspection, and what I've learned are meditative techniques without any medication. And while I do run the risk of crossing that threshold again I have become adept at noticing when I am approaching it and correcting course. Every year I become more confident in my ability to stay balanced and I no longer experience the negative effects I endured while treating it as a disease.

It's weird that we consider mental illness to be a disease, in my opinion -- none of the drugs have been linked to physical/chemical shortages in the brain or the like. We're able to mask symptoms but have absolutely no proof about underlying reasons, and so we create names of things and put it in the same classification of a medical disease... but that's very different.

Bipolar cannot be identified by any physical means. Different doctors will tell you different things. I agree that gradient approaches are useful in most contexts, but I am very hesitant to use this when a drug can be prescribed (with knowing bad side effects) can be applied. It can seriously mess someone's life up.

Mental Illness as defined by the DSM as not thriving. You can have the symptoms of a disorder, but if you are thriving then you do not have the disorder.

>It can seriously mess someone's life up.

Treatment to try fix someone who is not thriving, is precisely because someone's life is already messed up. Yes treatment may make it worse, but it often makes it better and there are treatment algorithms where we use best practices of how to go from here, and what signs should we be mindful for often when the meds make things worse the doctor should be asking the right questions for there are warning signs when the med is making things worse.

The DSM is based off the "top" Psychiatrists at the time voting on the illnesses (literally), without scientific backing.

Treatment's don't fix anything, they might lessen one issue and often give a host of other problems that are often more severe. I think more studying of iatrogenics is in order and more data about what "making it better" means -- as often the patient and doctor have different meanings. Again, because there's no physical symptom, you can't say "levels have returned to normal".

If you were feeling depressed but now you feel nothing, is that better?

The DSM can perhaps be viewed as a field guide to systems we can see the outer manifestations of but have limited deep insight into.

> The DSM is based off the "top" Psychiatrists at the time voting on the illnesses (literally), without scientific backing.

What, precisely, would provide scientific backing here, if a vote by professional scientists doesn't count? A vote by academics? A committee of academics, appointed by a prior generation? A team at Harvard, because Harvard is the oldest? A committee appointed by the government?

I believe their problem was with the structure of the process, and not with the composition of the governing body.

As Talanes mentioned -- the problem is with the decision method not the governing body. Again, comparing to the medical industry, where doctors don't vote on the existence or not of a virus causing a problem.

Doctors kept thinking I had a mental disorder. Several years of horrible experiences with medications were a waste Turned out it was a blood disorder. Proper treatment actually solved problems.

Depression meds just meant I was cool with my mind not working right.

I get some people are bipolar and such, but I think a lot of people have an underlying disorder they’re unaware of.

Part of the diagnostic process is supposed to be checking for "non-mental" things like blood disorders, by doing blood tests and other evaluations. So it sounds like you went through a flawed diagnostic process. Unfortunately that is far more common than it should be. The best way I have found to mitigate that risk is to have an advocate with you (family member or close friend) whenever you talk to doctors or other medical personnel about diagnosis or treatment--preferably someone who isn't afraid to ask tough questions and be skeptical of what seem like cookbook answers.

That was part of if. I had to bring someone to more or less break down in tears or yell at the doctor to get them to listen.

Had several years of only basic blood work run. Check kidney function and the sort. Mri were always clean.

This was across 20+ doctors. I had one that actually guessed correctly, but wasn’t his specialty. The specialist didn’t believe me.

Later I realized the specialist was using very outdated diagnostic criteria. As it turns out this is very common.

> Mental Illness as defined by the DSM as not thriving

Isn’t that a two-system measure? The person. And their society.

A gay man in Tehran won’t thrive, but the solution isn’t medicating him into submission.

> Isn’t that a two-system measure?

Usually, three, because the specific “not thriving” criteria usually have a degree of subjectivity, so it's patient/society/clinician.

Yes, it is, and that's precisely why the removal of homosexuality from the DSM (in 1974) was not a sign of the DSM's authors giving into cultural pressures - it was a combination of the authors avoiding the cultural pressures that had caused the previous edition to list it, plus a realization (after scientific study) that the problem wasn't with the person, it was with their society.

The nature of the scientific method is that we learn new things over time, and the nature of society is that we are all subject to various kinds of cultural pressures, most of which we don't even recognize. The meta-level goal of the DSM - describing those disorders which prevent someone from thriving and are properly treated by psychiatrists - seems sound, even if each edition always needs to be succeeded by a new one.

Yes. From page 20 of the DSM,

> Definition of mental disorder

> A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.

I'd personally believe there are physical differences even if we can't see them yet, but there's no proof until we do see them one day. It depends if you subscribe to dualism or not I suppose. Until then we are finding fire through smoke.

A spectrum will be based on a society so over time "normal" can shift. I wonder how many times that has happened? I've heard the USA as a population is typically very extroverted compared to many other countries, so perhaps that's one case.

The problem is that even if we can do a 'perfect' brain scan and figure out consistent correlations in how its structure differs for people with various disorders, it still doesn't really help us all that much. It would be like doing a perfect read of a hard-drive and seeing correlations without understanding (for the most part) what the ones and zeroes actually mean.

> I am very hesitant to use this when a drug can be prescribed (with knowing bad side effects) can be applied. It can seriously mess someone's life up.

This is why it's so important to understand that psychiatric treatment must be a collaborative process. The prescribing physician is only making decisions with the consent of the patient, because the patient is the one who has to choose to actually take the medication anyway.

Those decisions are made based on the patient's description of their experience of the disease. A medication can only push you in a certain direction, and when trying to find the right direction, all the clinician has to go by is what the patient says they're experiencing.

If your psychiatrist is simply telling you what your problems are, and prescribing you medications without your say in anything, then what you are receiving is not treatment. And it will, as you say, seriously mess [your] life up.

What about patients who present a serious risk of harm to themselves and others? Should they be medicated without consent? Sometimes the only other option is indefinite confinement in a mental facility.

Asterisk. I meant in the long term. In the very short term, hospital can be an option, but asylums no longer exist in first-world nations.

Our treatment systems simply do not currently have an effective long-term way of handling patients that outright refuse to take their medication.

In practical terms, these days most people in that situation end up in prisons instead.

My experience (and anecdotally the experience of many people I know) is that because a psychiatrist's proverbial hammer is medication, it's really important to either try other things first (like a psychologist who doesn't immediately send you to a psychiatrist) or to at least make sure you have sources of advice/expertise other than just a psychiatrist.

This is in The Netherlands, where AFAIK we're not particularly known for overprescribing medication, and our health care provides caregivers with enough funds to not go for the 'easy' pill solution right away. I imagine it's quite a bit more an acute risk in the US.

We knew what scarlet fever looked like & could do for at least two thousand years before the creation of germ theory.

I'm not sure where you get your information, but mental illnesses certainly can be identified by physical (neurochemical) differences from a statistical baseline. Probably one of the easier ones to identify is dopamine deficiency and dysthymia.

Drugs can certainly mess up someone's life (see my earlier post). But untreated mental illness can literally end your life (either directly, via suicide, or indirectly, via medical complications from body dysmorphic conditions)

I've studied it extensively. Please provide evidence to the contrary.

Here's one of mine about ADHD: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1518691/

While this may be true for Bi-Polar disorder (I'm not as familiar with this), there are some mental disorders that do display as differences in the brain (such as ADHD).

However, while these differences can't be rectified with medication or other therapies (yet), the side effects of these differences can be ameliorated by medication.

ADHD has not had any proof about differences in the brain: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1518691/

> Bipolar cannot be identified by any physical means

Most diseases couldn't be at one point and many still can't be now.

> none of the drugs have been linked to physical/chemical shortages in the brain or the like

That's certainly not true. These things aren't understood very well, but it's not at all true that there's NO understanding of how brain chemistry and mental illness interact.

> It can seriously mess someone's life up.

In general drugs for bipolar are prescribed only once someone's life is already "messed up". You seem to be invoking something like the hippocratic oath, but please believe that's already a solid criteria in medicine. These drugs are prescribed because they are known to work (no, not always and not with any certainty, but that they work is not meaningfully disputed).

People with dementia, which is often driven by clear physical processes (like cell death), exhibit symptoms of mental illness.

They unquestionably have a disease and often respond to drugs.

> We're able to mask symptoms but have absolutely no proof about underlying reasons, and so we create names of things and put it in the same classification of a medical disease... but that's very different.

I remember talking to a doctor and saying pretty much the same thing.

He looked at me, chuckled, and told me that I have no idea how much there is about so many 'medical diseases' that doctors don't know the 'underlying reason' for, and how many of the typical treatments are really just a "hey it seems to work without (too many) negative side effects, but we don't know why. ¯\_(ツ)_/¯."

> We're able to mask symptoms but have absolutely no proof about underlying reasons

That's true for a ridiculously large amount of non mental illness diseases, too. In fact, I'd say the majority of non-microbial/cancerous diseases fall into this category. Off the top of my head, one example would be Alzheimer's, where recently what was thought to be the "underlying reason" for Alzheimer's (amyloid plaques) have been proven to be a later symptom, not the actual cause. [1]

Most autoimmune diseases also have similar problems. Turns out it's hard to figure out how the human body works.

[1] https://www.nature.com/articles/d41586-018-05719-4

Well yes. But that shouldn't be much of a surprise to anyone, humanity isn't made of absolutes or boxes or borders.

A spectrum you can be 'on', as the word suggests, is just a range or a degree within a classification so we have a common concept when communicating about things. If we had to develop a new word for every unique combination of attributes it would become very hard to talk about things.

Not only are we all somewhere on a spectrum, we’re on a linear combination of different spectra.

As far as I understand, this kind of thinking is especially visual with Diabetes.

People have different levels of insulin sensitivity, which changes over time with thing such as diet and excercise.

Then magically one day you cross some arbitrary barrier, and you have type 2 diabetes. Crazy.

Only recently has this even been taken under scrutiny, and the phrase "pre diabetic" is used more. But it's clearly not enough.

I think the key to unlocking this is getting more people into measuring their insulin sensitivity through products like Veri[1]

[1]https://www.veristable.com

Great example of that barrier is gestational diabetes, which may as well be called secondary type two diabetes.

It’s not a rubicon, either, since it’s so commonly reversible (though this isn’t trivially easy).

I've always thought about mental illness in this context - we define it as illness because of negative consequences, but it's really just the deviation from a norm.

I think Elon Musk is the best example of this - even ignoring some of his childish Twitter behavior, the guy's brain is waaaaaaaaay far off from the normal human brain. He thought he could start an electric car company from scratch and be successful. That's... crazy. And yet, because he's been successful at it, we don't label him as mentally ill.

The really interesting cases are people like artists - David Foster Wallace committed suicide because of his depression, but only after creating one of the great works of American literature. We label him as mentally ill for his depression, but we don't really have a label for the positive side of the fact that his brain was far from an average brain.

I would suggest a meaningful interpretation of the word normal is kind of like 'a reliably orthogonal measurement of the thing being reacted to'.

> He thought he could start an electric car company from scratch

Except he didn't. He invested in one that was already started with several employees, and had himself given founder status by fiat as part of the deal.

At what point do you consider a company founded? At the moment the business is registered by the local government?

Well, when 3 guys start it and work on it for a long time, incorporate for a year, have an office and employees, and then a VC comes in, the VC definitely did not "found it", no matter when you define the actual date.

https://web.archive.org/web/20150228163500/http://www.busine...

Regardless of how elastic you can get with the term "founded," the actual assertion of "founded from scratch" is much more specific.

From what I have heard, Musk bought the electric car company and not built it with his bare hands in his garage in college. But to your point, everyone is on the spectrum sure.

>I think Elon Musk is the best example of this - even ignoring some of his childish Twitter behavior, the guy's brain is waaaaaaaaay far off from the normal human brain. He thought he could start an electric car company from scratch and be successful. That's... crazy.

Tons of people have started successful mega-companies from scratch. What's crazy, as opposed to ambitious and with slim chances of success due to practical reasons, about it?

> David Foster Wallace committed suicide because of his depression, but only after creating one of the great works of American literature. We label him as mentally ill for his depression, but we don't really have a label for the positive side of the fact that his brain was far from an average brain.

I'm a huge DFW fan, but I'd hesitate to use him as an example, for various reasons.

First off, from what I understand he stabilized on particular meds but then quit them because he felt he'd be more creative without. Instead of being more creative, he slid back into depression and the medication didn't work anymore (apparently that's a thing? I'm not too familiar with anti-depressants).

While I won't make any judgment as an outsider, it's not unreasonable to argue that he made a really bad gamble. It's quite possible that the it wasn't the medication that kept him from producing his next great work, but rather just the difficulty of what he was trying to do after Infinite Jest. Reading about it, it reminded me of various artists who 'jumped off the wagon' to return to previous glory, only to rediscover what being off the wagon really meant.

Furthermore, his struggles with depression and suicidal ideation, as well as drawing his self-worth from his work seemed to be a running thread in his life.

That said, his brain clearly wasn't average and I'm sure it played a positive role in his work. I'm just arguing against the common 'trope' that to do his work he had to be 'mentally ill'. I don't know either way, I just hold hope that these two don't need to be mutually exclusive.

I'd long believed that cognitive issues like autism are on a 2 dimension spectrum and that all of us lie on it.

Perhaps something similar applies to the personality disorders. However those disorders tend to overlap; I can't imagine the geometry that might to represent it.

What practitioners call mental health problems a "disease"? Surely that should be reserved for things like Covid or the plague?

They all have two aspects, the cause and the disease it triggers.

COVID-19 is the disease caused by the SARS-CoV-2 virus like AIDS is caused by HIV.

It gets complicated where they don't know or understand the cause like a lot of autoimmune diseases.

> like a lot of autoimmune diseases.

I worked for some years in a lab testing for auto-immune conditions - we called it that - a condition. I suppose other labs might have labelled it otherwise.

Would you call cancer a disease? I wouldn't.

But I suppose this is just arguing over semantics.

It is semantics but then words matter if you're the one affected - having the doctor say you have a condition would be better than having a disease.

I guess it depends on your definition of disease, which is technically broad in the literal sense of an abnormal negative medical condition. A condition in itself can be positive or negative and also has an implied connotation that it's just the current state.

Seem to be hitting that original argument about labeling things that are on a spectrum, where a condition could becalled a disease once it reaches a cetain state. Disease does imply a level of sickness and incapacitation, and maybe a permanent state?

Alternatively we could classify and reclassify disorders but the general public gets left way behind.

EDIT: There's also the notion that a disease is something you catch, which given our understanding of viruses and bacteria in triggering various diseases and conditions (and potentially some cancers) maybe excludes genetic and environmentally caused conditions?

I would ascribe the exact opposite feelings to the permanency of condition vs disease. Disease feels like something you get, you fight off, and you get better. A condition feels like something that you deal with and plan your life around.

Yeah, your right. I added in that disease is historically thought of something that you catch (and hopefully get over). Conditions can also be categorised as chronic which would be that permanent state of you have it, deal with it.

There is a good video done by Philosophy Tube about this subject (it also talks about Jordan Peterson.)

Some words are inherently subjective, like we can't define what "healthy" is without using so many words that are beyond description. (About 10 minutes in this metaphor appears, when Philosophy Tube references Richard Boyd.)

https://www.youtube.com/watch?v=SEMB1Ky2n1E

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