FreePsychArticles#13 The Ecology of Psychiatry, Part II: Arousal and Diagnosis
Accurate diagnosis is the basis for all clinical intervention in mental health. There are known short-comings in the current model of psychiatric diagnosis, which may be effecting the successful treatment of an untold number of patients. Mental health professionals are a worthy and dedicated bunch of people, doing a difficult job. In spite of the limitations there are numerous emerging approaches with potential to enhance diagnosis and treatment. Unable to start back at ‘square one,’ the emphasis is moving beyond conventional diagnostic structures to conceptualize more fundamental ground states underlying all illness. In the current article I will focus on the current disconnect of conventional diagnostic criteria with these foundational ground states. This is especially true for the DSM IV used in all spheres of psychiatry today.
There has been a lot of controversy in the development of the Diagnostic and Statistical Manual, fifth edition (DSM-V) currently underway. Dr. Al Francis, a lead editor in the development of the DSM IV has come out with serious criticism of the proposed manual, pointing out its shortcomings. He says, “there is no definition of a mental disorder…I mean you just can’t define it.” He has, in fact, launched a “bitter and protracted battle with the people, some of them his friends, who are creating the next edition of the DSM in a very public way, to include the general public.” (From Wired, Jan. 2011 edition).
In “Ecology & Psychiatry, Part I”, I began working on ways to describe the phenomenon of “arousal”as basic and more fundamental than diagnostic categories. The state of arousal is an innate aspect of living organisms. The more differentiated the organism, the more the individualized the state of arousal can be. I speak in macro-cosmic terms since there may well be great variations from say, one insect to another. But those theoretical variations, although outside the sphere of relevance to psychiatric inquiry, do fall in sync with the overall picture of paced pulsing levels of energy expressed through the arousal of given individuals.
I learned the basics of the DSM III in the early days of my psychiatric training. As time passed I discovered most patients did not fit into the diagnostic criteria. There are often ‘spill-over’ of symptoms and signs beyond diagnostic boundaries. Often, to be usefully accurate, it required more than one diagnosis to encompass all of the findings. Often dramatic arousal states found non-expression or non-inclusion in DSM diagnoses. The DSM IV purposely avoids underlying cause of disease expression. If the DSM is used with these limitations in mind, it’s not a bad system for organizing symptom-cluster states. Since psychoactive medications of today are used across diagnostic categories boundaries one does wonder what function the manual actually serves?
In clinical work hyper-arousal is a fairly consistent finding in Bipolar Spectrum Disorders in which “distinct periods of elevated, expansive or irritable mood” are necessary. These mood variations must be accompanied by inflated self-esteem or grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractibility, increased involvement in activities, psychomotor agitation, and excessive involvement in pleasurable activities lasting at least a week.”
It’s not a stretch to consider a “furnace of arousal” as the energy source for these symptoms. Ostensibly, once successfully treated the mood returns to “normal.” In my experience the overt and prominent symptoms do diminish in amplitude but frequently underlying hyper-arousal remains. The 8-Signature Array, a diagnostic test, shows expansiveness, accelerating enlargement of signatures and increased pattern size in bipolar patients long after the manic state has been treated. When someone, in the absence of available history, presents with presumptive depression it is often difficult to diagnosis bipolarity. They may have no recollection of the prominent signs and symptoms with episodic high-energy states, lack of need for sleep and increased gregariousness they see as “normal.” Yet they present with many depressive parameters like sad mood, lack of interest or drive, sleep problems and negativity. The 8 Signature Array handwriting test most often reveals acceleration in speed, size and other telltale signs of underlying hyper-arousal. This finding is not consistent with a true “uni-polar depression” where there would be slowing and reduced surface area. On further questioning the bipolar depressed patients would endorse report symptoms of agitation, difficulty concentrating, racing thoughts and irritability. The assumption is the hyper-aroused state drives one to “expand” neuro-vegetative energy in areas under the least conscious control or less integrated channels of development. (This also alludes to the idea of energy flow and utilization).
Hyper-arousal can be found in non-bipolar patients, who are often misdiagnosed as Bipolar. This is certainly true in some of the personality or character Disorders. They can have positive findings in moodiness, irritability, highs and lows, racing thoughts and anxiety without the clearly demarcated periods of mania, hypomania or depression. In fact I’ve come to think about the personality mood disorders as multi-polar rather than “bi-polar.” Their mood changes tend to orbit around interpersonal issues rather than the mood states themselves. The issue in this case is clearly hyper-arousal driving dysfunctional emotional response or acting out, in ways particular to the individual’s psychopathology.
A third example of hyper-arousal at the heart of a diagnostic entity is Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD). People with this diagnosis often present diagnostic confusion sometime during their lives once they enter the clinical environment. There may be crossover symptoms and signs although far less dramatic than chronologically mutable mood states of bipolar disorder. Whether they are diagnosed bipolar, mood disorder, conduct disorder or ADHD is more a result of convention or vogue. Their handwriting can be fast and expansive to reflect hyper-arousal as are their subjective reports. Non-stimulant medication can reduce some of their arousal while doing little for the attentional deficits.
Finally, patients new to the mental health system have frequently been functional throughout their previous lives. Once hit by one or a series of interruptions in life they may develop overwhelming symptoms. Middle age job-loss, divorce or other major stressors may have a domino effect on other areas of life. The energy or arousal level that was once normal and functional converts into symptoms difficult to contain. Their innate level of hyper-arousal has not suddenly appeared in the form of a psychiatric diagnosis, rather it has shifted course. The “energy channels” developed over years are suddenly blocked. The “arousal energy” once directed outward turns back on itself. This results in a kind of “building up steam” paradigm manifesting in numerous ways.
Clearly this “Arousal Hypothesis” lacks scientific rigor and peer review. Other than the 8-Signature Array and clinical impression it is not quantifiable nor does it conform to formal methodological research standards. I have attempted here to describe commonalities of nature that crossing conventional diagnostic definition,which I’ve encountered over the course of 24 years of clinical practice.
In Parshas Tazria, in the Book of Exodus, there is a description of a kind of malady called “tzaras.” In English translations it is frequently called “leprosy” and confused with the medical condition of the same name. Correctly, it is actually a spiritual condition brought about through certain transgressions of Torah Law that manifest in stages, first of which is a coloration on the face or beard. If “untreated” it progresses to the clothing and finally to the stones of one’s house. In contrast to our current medical model, a physician is not brought in for diagnosis and treatment. Rather, it is the Cohen, or priest who performs these tasks. He alone can properly pronounce the diagnosis and the formal practices required to bring about a cure. The diagnosis and the underlying cause are the same. The adjustment in the “patient’s behavior” brings about the cessation of the symptoms. In our modern life we’ve placed layer upon layer of “stuff” between ourselves and our own Spiritual connection with G-d and Essence. Science has been unable to “prove” or disprove the existence of this immeasurable G-dly Effervescence that pervades all existence. In the Torah all disease is spiritual in nature and cure.
How does this relate to us and modern maladies? How do values and behavior effect our mental health? How can we incorporate these into treatment approaches for more relevant, holistic solutions? Finally, can a conscious eye to underlying arousal states enhance diagnostic accuracy by forming a bridge beyond symptom clusters to less differentiated emotional energy experience?
These are some of the questions I will try to address in future articles.
Gershon Freedman, M.D.