It had the makings of an epidemic. From 1994 to 2003 the number of children diagnosed with bipolar disorder—a condition characterized by cycles of devastating hopelessness and despair followed by times of ecstatic excitement—had skyrocketed. In 1994 only twenty-five of every hundred thousand American kids under the age of nineteen were diagnosed as bipolar. But by 2003 the number of cases had shot up by a staggering forty times. A doubling of this rare but serious condition would have been newsworthy in its own right, but a fortyfold increase made it clear something was going on. The question was what.
One explanation is that there was a surge in the number of kids suffering from the disorder. But the diagnosis of 800,000 children in 2003 alone, compared with 20,000 per year just a decade earlier, signaled a radical change—a fundamental shift, perhaps, in the process of growing up. But no such change had been identified. Moreover, because bipolar disorder involves a heightened risk of suicide, if its occurrence had increased, we’d expect to see a corresponding spike in suicide and attempted suicide rates among young people. Over this same period, though, suicide rates among America’s children didn’t rise at all—in fact, they went down by 23 percent.
Another explanation is that the number of kids with bipolar disorder had always been large, but that in the last decade more parents had begun to seek psychiatric help for their children. The problem with this theory is that if there had been a massive stampede to psychiatrists, it stands to reason that diagnoses of disorders other than bipolar would have increased as well. But there was no such surge.
And this brings us to the third possible explanation: if the number of children suffering from bipolar disorder hadn’t increased, and the number of parents seeking psychiatric help for their kids hadn’t increased, maybe all that had changed was the number of children being diagnosed. Not only does our exploration of this theory take us deeper into the two diagnosis traps we explored in the last chapter, it also uncovers a new and powerful trap that affects both the person with the bias and the person being diagnosed.
It turns out that even the medical community is not immune to the lure of the diagnosis bias. As the job interviewers taught us, one of the traps in diagnosing is that we tend to rely on arbitrary information. To understand how this force contributed to the bipolar epidemic, we must cross an ocean and travel back in time to the tumultuous world of pre–World War II Germany. There a psychiatrist named Emil Kraepelin was developing the first categorization scheme for mental disorders. Instead of relying on objective, scientific data, Kraepelin used his own intuitive judgment to arrive at the diagnostic scheme. Some of the labels he developed are still used today, including manic-depressive disorder, also known as bipolar disorder. Some of his other diagnoses, however, are more obscure and, frankly, unnerving—such as his category of “individuals with distinctly hysterical traits,” which included “dreamers and poets, swindlers and Jews.”
Nonetheless, psychiatrists found Kraepelin’s diagnostic system to be a useful tool (he’s regarded as the father of modern psychiatry) because it created an analog to the medical model of diagnosing diseases. If a patient visits a physician and complains of a sore throat, headache, and fever, the doctor can do a quick examination, diagnose strep throat, and administer the prescribed remedy. Similarly, under Kraepelin’s system, a patient who sees a psychiatrist and exhibits symptoms of bipolar disorder can be diagnosed and assigned a course of treatment, be it therapy or medication. This medical model of diagnosis has proven popular with psychiatrists up through the present day.
In 1980 the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) broadened the definition of bipolar disorder to include individuals with less pronounced symptoms. No longer did the diagnosis require previous hospitalization for a manic episode. The new diagnostic now included such commonplace descriptors as “feel[ing] sad or empty” “appear[ing] tearful” exhibiting “fatigue,” “indecision,” or “insomnia” being “more talkative than usual” suffering from “distractibility” or having “inflated self-esteem.” Even individuals who met only some of these criteria could now be included under the bipolar umbrella.
On top of that, as British psychiatrist David Healy explained, in the 1990s pharmaceutical companies increasingly began to draw attention to this formerly rare and relatively unknown condition. Their campaign included the publication of new journals, the establishment of bipolar societies and annual conferences, television commercials for new treatments, and frequent workshops for mental health providers. During that time it was difficult for either parents or therapists to avoid hearing talk of bipolar disorder. What followed, said Dr. Healy, was a snowball effect. The more bipolar disorder was placed in the spotlight, the more clinicians were exposed to it, the higher the diagnosis rate climbed, which in turn led to further diagnosing. Factor in the new symptom standards for the illness, and the bipolar epidemic became so widespread that a Massachusetts hospital treated groups of preschoolers. Healy reported that even a two-year-old has been diagnosed with the disorder.
Now, the bipolar designation was arbitrary for a few reasons: Kraepelin had relied on his own perceptions, rather than on hard science, when categorizing the mental disorders; the DSM-III broadened his original definition in 1980; and pharmaceutical marketing campaigns since then had attempted to bring more people into the fold. Primed to be on the lookout for bipolar disorder, psychiatrists started seeing it everywhere they looked. What many of them failed to recognize was that they had fallen into one of the traps of the diagnosis bias—arbitrarily assigning labels.
On its own, relying on arbitrary information causes enough problems, but this inclination is further complicated by the other trap of diagnosis: our tendency to ignore objective data that contradicts our initial diagnosis. To gain a deeper understanding of how this trap plays out, we talked with psychologist Bruce Wampold. Dr. Wampold is the kind of man who believes in empirical, quantitative evidence and objective data. He used his degree in mathematics and his psychological training to analyze what it is that makes psychotherapy work. His adherence to quantitative evidence meant that Wampold had to rely on large enough sets of data to make sure he was capturing all the relevant factors. It was only after taking into account every relevant scientific study on the effectiveness of psychotherapy that he began his meta-analysis.
~~Sway: The Irresistible Pull of Irrational Behaviour -by- Ori Brafman
No comments:
Post a Comment