It could be like this.
A person is born with unrecognized alterations in brain function; maybe it is genetics, maybe it was the pregnancy, but something is different. The child looks hyperactive, inattentive, and moody by elementary school. School performance is poor. The difficult social behaviors lead to bullying, harsh discipline, and trauma. The parents are exasperated and turn to punishment and abuse to manage the child. By adolescence the ongoing trauma, coupled with low self-esteem and social exclusion, leads to an escape into drugs and alcohol. Thereafter, romantic and intimate relationships are unstable; identity is unstable; the future looks vague and bleak. Soon, the memories of all the bad times start popping up, and each day is filled with anger, upset, anxiety, and fear. The first depression hits, the second depression hits. Sobriety is partially achieved, but the moods keep coming, the trauma memories still there. The anger now starts to worsen for longer periods of time, say the occasional week of raging (or bitter, reckless partying) followed by despair and remorse which lasts for a few weeks. Eventually, antidepressants are tried. It gets worse. It crumbles with a visit to the ER after an impulsive suicide attempt, taking Tylenol in a state of great distress, anxiety, insomnia, agitation, anger, flashbacks, intoxication, and irritability.
See, that’s the rub. A typical doctor would say anything from Borderline Personality Disorder to Depression to Adjustment Disorder. A clever doctor would say it’s both BPD and Depression. A SCID-V interview (Structural Clinical Interview for Diagnosis with the DSM-5—currently draft version from Columbia U.) would reveal something entirely else. It would show ADHD, Borderline Personality Disorder, Substance Use Disorder, PTSD, and Bipolar Disorder II, currently in a hypomanic state with mixed features. How could all that be true?
I firmly believe it CAN all be true. I think of it as a montage of symptoms unique to one person’s complicated journey through life, which reflects original genetics and constitution (“What you Are”), admixed with life experience (“What Happened to You”), and that person’s struggle to belong and form an identity (“Who You Are”).
Thus, I believe we should not balk at giving many, contradictory diagnoses: no one diagnosis captures the full picture, and many diagnoses highlight the myriad facets of what is essentially a very complex thing—a human being.
Remember, diagnostic tags are only useful for making treatment decisions by professionals, or it is for psychiatric research. So, until we find our way to another diagnostic scheme, like the Research Domain Criteria (RDocC) proposed by the NIMH and it’s director, Thomas Insell, MD, we need to use the DSM-5.
A wise doctor knows that the DMS-5 categories are unable to really say much about who they are treating—the DSM-5 it is not a definition of personhood–but it sure helps guide what should be tried next.
Joris Wiggers MD