All these years ago In 2nd MB, in the dreaded dissection room, a cold echoing chamber suffused with the aroma of formalin which never leaves you, Dr Chinnan would blunt dissect with remarkable rapidity through the layers of fascia and muscle, to expose a nerve. “Here is the nerve. It has a name. Never mind the name!” And Richard Feynman as a boy used to go on nature walks with his father, who was not academic, but who had an insatiable curiosity about the world. He would say the same thing as Dr Chinnan. This plant has a long Latin name, and people think they know about it because they know the name. But just because you can name it doesn’t mean that you know anything about it. And Bertrand Russell wrote a seminal tract on, among other things, nomenclature, On Denoting. Just because you can name things in a fashion that is syntactically correct doesn’t mean that you are making any sense. The present Queen of France is dead.
Yet naming, labelling, seems to have become very important to us. Are you a woman because, despite your 46XY chromosomal endowment, you know deep down that you are? Does the activity of Israel in the Gaza Strip and the West Bank constitute genocide? And, this week especially, do one in four children carry the diagnosis of either autism, or attention deficit hyperactivity disorder? Wes Streeting the Health Secretary in England was minded to suggest that these days such conditions are being overdiagnosed. On the contrary, said many consultants in child and adolescent psychiatry, they are being underdiagnosed. The health secretary backed off, to an extent. He is more than happy to take on the BMA, but less inclined to get offside with the medical profession as a whole. On Any Questions last week Shami Chakrabarty commended him for eating a large slice of humble pie; something of a morganatic, or backhanded compliment. I’m not sure he did. He ordered a review. He is clearly concerned that once a young person has been labelled with a psychiatric diagnosis, he or she is liable not only to be signed off, but written off, removed from the workforce, and put on benefits effectively for life.
But is this urge to append a label to everything helpful? Woman, genocide, neurodiversity… You can debate definitions endlessly, but these debates are purely semantic, and often rather recherché, like how many angels can dance on a pinhead, or how many daughters had Lady Macbeth? Better put these issues to one side, and go deeper into exploring the fine grain of human problems. Should a 46XY individual have the right to enter a sport’s dressing room designed for 46XX individuals? Has the response of the Israeli government to the attacks of October 7th 2023 been proportionate? Would a young person who cannot sit still and concentrate benefit from some extra help?
The number of neurodiverse diagnoses has skyrocketed since Covid. People wait an age, even half a lifetime, for the diagnosis, and another age for any form of intervention. Have the number of cases really increased, and if so, why? Are they merely being better recognised, or are people truly being overdiagnosed? My hunch – and it is only a hunch – is that all of the above are true. Much has been said about the deleterious effects of Covid, and the associated lockdowns, on mental health. But, as has been pointed out, the increase in child and adolescent mental health problems started before Covid. I’m more persuaded by the recognition of the malignant influence of electronic devices. I remember attending an RSNO concert last year when a mobile phone went off during a performance. Maestro Sondergard begged the audience not to bring their contraptions into the concert hall. “They are making us all ill.” That I think is, literally, true.
In many ways society is much kinder now than it was when I were a lad. I recall some of our teachers were very free with the use of the tawse. One teacher administered a spelling test once a week, the ground rules being that two mistakes earned you two strokes of the belt. I doubt if he had ever heard the word “dyslexia”; I don’t suppose that at the time, anybody had. Another conducted forty minutes of Religious Education once a week, in which the class was required to memorise two verses from the Psalms. At the end of the period he would select a pupil at random to give a recitation by heart. Failure to be word perfect evoked the same dire punishment, and he was a ferocious belter. At the time, I don’t suppose ADHD appeared in DSM 1. Still, I’m glad I attended school then and not now. I couldn’t bear the integration of the digital world, social media, and information technology into education. I’m quite sure it would have driven me, literally, mad.
Are the psychiatrists overdiagnosing? Actually I think the entire profession is overdiagnosing. Everybody is on the spectrum of something. No one is normal, and there’s none so queer as folk. You go to the doctor with your own agenda, only to discover that the doctor has an agenda of his own, and it is a desire to place you somewhere on the spectrum of something. I wrote the other day in this blog about a lawyer who said to a room full of doctors, “You think when you consult us that you are inviting us into your world. On the contrary, it is we who are inviting you into ours.” Nowadays a GP might say the same to a patient. Before you know it, you are being screened, and vetted, and put on the spectrum of pre-hypertension, pre-diabetes, pre-hypercholesterolaemia, pre-you name it. I don’t suppose practitioners working in mental health are any different.
I was never taught to practise in this way. Medicine used to be clear cut. Patients either evinced a clinical sign, or they didn’t. They either had a diagnosis, or they didn’t. Of course you might argue that the concept of “diagnosis” was, is, entirely a human construct. In reality there must be a spectrum of normal to abnormal, from health to a sickness which is mild, moderate, or severe. And there must be, temporally, a point at which normal becomes abnormal. You might argue that pinning a diagnosis on somebody is the same as pinning a label on them; it’s a semantic exercise. The truth is that the diagnosis, the label, is not the end of the story. Here, practitioners in somatic medicine can actually learn a trick from their psychiatric colleagues. In the template of the classical psychiatric consultation of history and mental state examination, the diagnosis is immediately followed by an entity known as “formulation”, a reasoned application of the diagnosis to the unique circumstances of the individual patient. This is what we need to do; apply the data extracted from the “case” to the unique individual before us. Every diagnosis, and every ensuing treatment or management plan, is custom-made. But individuals are in danger of being anonymised and swallowed up within populations.
So Dr Chinnan and Prof Feynman were right. What’s in a name? It’s only a heading. What matters is the underlying formulation. We might all learn from the psychiatrists, not just other doctors, but politicians, “influencers”, polemicists, culture warriors… Ask the question, what’s actually going on here? Think pathophysiologically.
jamescalumcampbell 