Tuesday, August 16, 2016

Worried Well, Subclinical Sickness, and your Right to Seek Health

[This isn't a post about psychiatry, but I'm going to start there... please bear with me.]

I'm not a psychiatrist, but I dated one for a year and a half, so I'm highly qualified to talk about all things having to do with psychiatry.

Psychiatry is especially interesting to me because psychiatry has a long tradition of acknowledging that its field is hard to define. What constitutes a psychological illness, exactly? The question was considered difficult enough that the American Psychiatric Association publishes a book (the DSM) to list the "Mental Disorders," and disorders are added and removed from the list with each revision (homosexuality being a particularly famous example of something listed as a disorder in earlier revisions, then removed).

While there is plenty of controversy around the DSM, I'm sure there are also plenty of core disorders that we can all agree 'count' as mental disorders, mental conditions that make a person an immediate danger to themselves or to others. But there are equally lots of mental conditions that we'd mostly agree are on the opposite end of the spectrum. Suppose someone is feeling anxious because of a difficult job situation, and has some trouble sleeping. It would be strange to call that a mental disorder, or to say that person is ill. Yet I also think we'd agree that it would be nice if that person could get some help.

Luckily, the psychiatric community has a term (which I love) for people who might want some 'help' with their mental condition, yet don't qualify as actually having a full blown mental disorder - they're called the "Worried Well."

What I love about this term is that it expands the scope of practice of practitioners in the psychiatric community to those who might not have diagnosable mental disorders. It says, "you don't have to be REALLY sick in order for us to try to help you."

I don't mean to suggest that this notion is altruistic. Obviously, psychiatrists and psychologists don't want to restrict themselves to patients who fit in to some category in the DSM-V, they need to make money. But it's still a valuable notion, that nearly anybody experiencing psychological suffering, even if it's not DSM-V worthy, can legitimately seek and possibly receive help.

For a variety of reasons, some historical and many economical, many (not all) non-psychiatric physicians are less likely to acknowledge, treat, or research concerns that don't meet the criteria for an actual diagnosis. I like the term subclinical to refer to these things.

What do I mean by subclinical?

Suppose someone feels tired and worn out all the time, but not to the point where that person can't hold down a job or fulfill their responsibilities. What's a typical doctor going to do about it? Probably run a bunch of tests to rule out things like cancer, anemia, and a host of other disorders that count as an actual diagnosis that can be checked off on a electronic medical record or submitted to a billing company. What if those tests come back negative? I'm sure many decent doctors would make some generic recommendations, like telling that person to sleep better or improve their diet, but generally speaking there won't be any aggressive pursuit of any remedy.

Have a lower libido then you had as a teenager? Your physician might test your hormone levels, but if they come back within the normal reference range you're probably out of luck. You might get a casual recommendation to try some herb, but rarely more than that. If you're older and have minor aches and pains many physicians will just shrug and tell you to make the best of it.

I'm not blaming physicians. They need to put something on the bill they send to the insurance company to explain why they treated you, and "feeling meh" is not a box you can check (I looked).

There's a trickle down effect from this. Since physicians aren't really in the business of treating issues that don't qualify as an actual disorder, they're not really interested in doing or reading any research on the topic. And, to be honest, it's probably a lot harder to research "causes of feeling not too great," simply because feeling not to great is very hard to measure and quantify.

Things are improving in some ways. I know there are tons of great doctors who try to help any way they can. Doctors who specialize in functional medicine often seem to address these subclinical concerns more seriously. I'm sure that in other scenarios where you are willing to pay out of pocket for treatment you can get a physician to take these things seriously. But in my experience there isn't a very broad middle ground between the physicians who will treat what your insurance will cover and the very expensive ones who will do whatever you ask for because you're paying through the nose for it. And even if you find the physicians who will help you with your subclinical issues, they don't have the same body of research to fall back on that they do for diagnosable disorders.

But without the guidance of a physician and the medical establishment, most lay people end up turning to the internet, or their personal trainer, or the salesperson at GNC, or their hairdresser, or whoever, to find 'solutions' to what ails them. And sometimes that information turns out to be helpful, and sometimes, not so much.

At this point, if you're still reading, even if you agree with what I've said, you might be wondering what the point of the article is. Well, there actually are several.

1. Keep in mind that medical research is aimed at the clinical, not the subclinical, in what it measures and how it evaluates results. So research that aims to determine whether gluten (see what I did there?) affects health can't, and won't really try to, evaluate subclinical effects. If you see some article headline claiming that, "Gluten Consumption Doesn't Impact Health!" they don't really mean that gluten doesn't make people feel slightly worse, because they didn't look at that. They only looked at whether gluten led to an increase in something diagnosable. The gluten they were feeding their subjects might have  made them all feel a little bit more meh (or blah if you want another adjective), but the researchers weren't asking that question.

2. You have a right to seek help for your subclinical symptoms. Ask your doctor about them, you might be pleasantly surprised. But even if your doctor won't help, try things on your own, like dietary changes, exercising more, more or less fiber, whatever (don't be stupid, don't try just ANYTHING), because you have a right to try to feel good. Just because some ailment or issue doesn't warrant major medical intervention doesn't mean that it's not real or that it's not meaningful.

3. If you can find a doctor willing to prescribe meds off label or seriously investigate your issues, try to do that. It might cost you something out of pocket; you have to decide for yourself how comfortable you are with that, and how much money you've got. [Note: there is room for a debate about how this sort of treatment ought to be paid for, in a perfect world, but I'm not interested in having that argument here.]

4. Other people might dismiss your concerns. I can't tell you how often people have suggested that 'avoiding gluten only makes sense if you have celiac disease.' We don't have a culture that emphasizes taking care of ourselves (for example, we don't value getting enough sleep, and we admire people who seem to function well on very little sleep, even though sleep is a key factor in maintaining good health). This is especially true of aging related issues. Many, many people will look askance at someone who wants to maintain their physical fitness into their later years. I'm not telling you to argue with those people, but stick to your course. If you want to improve your quality of life, do it. You don't have to have an actual disease to want to improve your health. And the fact that others approach their declining health and fitness with a fatalistic attitude doesn't mean you need to.

Many of us function suboptimally our entire lives, and we ALL lose functionality as we age. Not all, but many of those conditions can be treated, some by readily available lifestyle choices, some with prescription medications. If you're not operating at a level that makes you happy, change something! Your situation might not be fixable, but I bet you can feel better if you make the right choices.

And if you're looking for a good place to start when making those lifestyle changes, consider taking up a martial art!