Shadow Syndromes: Reviewer Gets It
the reviewer uses this text and his own experiences to write a good critique of the confining DSM classifications and to provide a realistic view of brain complexity that argues for spending more time treating patient's symptoms and less on figuring out which box(es) they fit into. his analysis (and more fundamentally, that of the book's author) illustrates the dangers of not doing so. please read.
"Shadows Syndromes is a worthy read, in that it does a good job of highlighting the major disconnect between diagnostic categories and reality. While the DSM model has its uses (research and billing being the only two I can think of right now), it also serves to reify the notion that mental illnesses are precise, discreet disorders. Any one with an ounce of clinic experience will tell you that real cases don't fit neatly into categories. The diagnostic questions sometimes help think through and organize the presenting concerns, signs and symptoms. But often the debate over whether someone is suffering from a pure mood disorder versus PTSD versus character pathology serves as a distraction. Or , another classic example: spinning wheels arguing whether a patient is an addict with psychiatric symptoms secondary to drug abuse or are they actually someone with a primary psychiatric diagnosis who is using substances to self-medicate their mental illness. It's a meaningless exercise based on an overly simplistic model. But that one does matter because insurance companies consider one of those scenarios worth paying to treat and the other worthy only of their contempt.
In reality, just like any other organ in the body, the brain mediates a number of functions. It is responsible for mood regulation, memory, sustaining attention, shifting attention, interpreting social cues, integrating sensory information, regulating motivation of all manner of behaviors, and impulse control, to name a few. We all have various strengths and weaknesses, and we all fall somewhere on a bell-shaped curve for performance of each of these various tasks. People who shake out on the extremes ends in one particular area probably look like textbook definitions of specific illnesses (a "pure" mood disorder with no other comorbidities). That's rare. Looking at it even just from this sort of statistical model, one would expect that, for any given disorder, the number of people who unmistakably qualify for a specific diagnosis would be just a fraction of those who almost qualify. These "subclinical" cases are what Drs. Ratey and Johnson refer to as "shadow syndromes." They go a step further and assert that these people actually suffer more from mental illness, because they slip through the cracks. They are not quite sick enough to find themselves needing treatment, but they are impaired by their symptoms.
It's an important perspective that is explained in simple, readable terms in the first part of the text. The second part then breaks the shadow syndromes down into specific "mild" mental illnesses based on the traditional categories. So just imagine how densely the comorbidities can layer now. Is there anyone motivated to pick up this book that won't conclude that they have masked depression, are slightly bipolar, have a subthreshold intermittent rage disorder, mild attention deficit disorder, a touch of "autistic echoes" and are a shadow addicts? Then what are the implications? Does everyone need to be in therapy? Does everyone need to be on a finely tuned psychopharmacological regimen and a behavior plan?
I recommend this book, I think it's well-written and thought provoking. It does succeed in explaining complex issues in a way that is understandable to people outside the field without being simplistic or dull to people within the field. That's a tough line to walk. And I like the emphasis on blurry boundaries to disorders, and the overall message of understanding how your brain works, what your relative strengths and weaknesses are and how to make the best of things. But I worry that the take-home message for many will be to feel these diagnostic categories expanding, billowing out of their margins, pathologizing every aspects of our humanity as it envelopes us. While it gets at the true complexity of these disorders, it also does so with the bias that mental illness primarily a Biological phenomenon. Perhaps this is to combat social stigma and people's assumptions that these deficiencies are due to personal weakness (or- just as damaging- all to be blamed on bad mothering). Or perhaps, it's that, as we learn more about these disorders (which we are doing at a rapid rate thanks to the new abundance of genetic data and advances in brain scanning that lets investigators see brain regions light up as they work), we learn more about the biological aspects, since that is what we are looking for and trained to interpret. So, now the authors expand the scope of these diagnoses and therefore lead us to the conclusion that more people could benefit from psychopharmacologic treatments. It's a nice book to recommend to your patients if you take only self-pay patients and only do psychopharm visits. But it skims over the real beauty of psychiatry, the reason it is the most intellectually challenging field in medicine and the most rewarding specialty to practice, which is the multifactorial, composite nature of everything our brain is and does at any moment. No doubt the genetics shape the brain, as does the metabolic and endocrine factors in the uterine environment during development, as does nutritional factors, and then near infinite environemental variables acting constantly on each individual. From things as foundational as the fit in temperament between primary caregiver and baby, all the way out to religion and culture. From the preconscious memories of the earliest childhood experiences all the way out to this morning's headline news.
You can take the best brain in the world, if there is such a thing, but I guarantee the individual possessing it will be no healthier than the families, systems, and societies they inhabit.
So thumbs up for a great read, and a perspective that broadens our view of the mind and mental illness. Too bad they interpret the new landscapes with tunnel vision, but it's to their credit that they left me wanting more. "
Labels: behaviors, BPD, humans, medication, psychiatry, psychology, sleep disordered, sociopathy, truth




