Friday, January 19, 2007

The Well-Worried Well

Psychiatric and psychological treatments are used to address a number of issues including, but perhaps not limited to: the symptoms of designated syndromes of mental illness (for example, schizophrenia, affective disorders, anxiety disorders, attentional problems, personality disorders), the behavioral consequences of symptoms of psychiatric disorders (such as crawling under the covers while depressed, promiscuity while manic, homicide while delusional), primary behavioral problems ( such as substance abuse, gambling), maladaptive patterns that may arise outside of a mental illness (Why do I always end up with creeps?), dissatisfaction with life circumstances (I haven't lived up to my potential), difficulties coping with life stressors which may or may not precipitate a psychiatric illness and sometimes are the focus of treatment even in the absence of illness (grief, adjustment disorders), or a desire to gain insight and understanding of one's self as a goal of its own ("The unexamined life is not worth living." Thank you, Socrates). That was a really long sentence. In short, and to use the lingo of my former chairman, Psychiatry looks at issues pertaining to mental life and behavior.

If you hang around long enough, the term Worried Well gets thrown about. It refers, I think, to those folks using psychiatric treatment to broaden their insight, to maximize their functioning (so why am I still driving a cab when I have a graduate degree?), to lead richer lives. It may refer to people suffering from Anxiety Disorders, rather than the more "serious" illnesses such as schizophrenia or bipolar disorder It refers to the stereotype of the neurotic, sometimes Jewish, New York, Woody Allen characters who obsess and worry --though I will point out that Woody makes criteria for many diagnoses very quickly. It sometimes refers to those suffering from Major Depression who should just pull themselves up by those blessed boot straps. Actually, I'm not really sure who exactly those Worried Well are.

The Worried Well is a term used, even by or especially by, psychiatrists with a bit of disdain, especially by psychiatrists who treat severe, chronic, and persistent mental illnesses. The broader question embedded in the subtext of the term begs: Who Warrants Care? How do we allocate our resources? What is worthy of the psychiatrist's time and attention, and who should foot the cost?

Most of the people who come into my office arrive while suffering. Suffering, it seems to me, warrants care, even though I'm occasionally left to say, "You don't have a mental illness." Suffering is sometimes just a part of life and life is often hard. Psychotherapy often helps, for reasons which remain a bit vague to me, sometimes medicine even helps in the absence of a mental illness (oh for a good night's sleep, or something to help that post-9/11 gotta-get-on-a-plane nervousness), but there are those who feel that psychiatric resources--especially those paid for by a third party-- should be limited to those with major mental illnesses.

It's a nice idea, but the lines get blurry. The more common scenario is that someone arrives in the midst of an episode of mental illness. They get better, usually fairly quickly. No longer in the throes of acute, intense, and miserable symptoms, the patient often continues to come on some regular basis. They still need their medications monitored, but it's more than that. Sometimes patients are afraid to stop coming-- fearful their symptoms will recur. Often, they say they feel better after a session. Many have periodic mini-flares in their symptoms-- normal variations in mood perhaps because moods do afterall vary some, but once someone's had an awful episode, they can get very sensitive to even little changes. Sometimes, it's simply hard stuff to articulate. And honestly, I've followed a number of people who show up regularly to talk about the stuff-of-life, who come despite a lack of symptoms, who at some point later on develop raging symptoms. Sometimes it's about alleviating symptoms, sometimes it's about preventing relapse, sometimes it's about holding on for the ride. Sometimes, I don't even know what it's about.

Does it need to be articulated? We take children to the pediatrician when their ears hurt. We don't say, oh it's probably viral, I won't waste the doc's precious time. How many unbroken arms get x-rayed, how many normal brains get scanned in patients with unremarkable neuro exams? And what about the zillions of screening mammograms and then diagnostic biopsies on all those women who
will never get breast cancer? Or the all those PSA's for men over 50? Many conditions get better without treatment, but we don't begrudge anyone a medical evaluation to be on the safe side.

I sometimes (-not a lot, the folks who wander into a psychiatrist's office are a self-selected crew) say "You don't have a mental illness." I've not yet said to anyone who's walked in while suffering, "Don't come for psychotherapy."

P.S. If you have the answer, by all means, comment!