You’ve experienced some swelling in your neck for the last three months and decide to see your doctor.
They do a physical exam and run some tests. At the follow up appointment, they give you the absolute last thing you wanted to hear.
“You have lymphoma.”
When I started medical school, a memorable preceptor told me that I was about to learn an entirely new language. An understanding of that language, she said, would empower me to become a wonderful physician.
Hodgkin’s lymphoma is an example of a disease. What makes a disease? The presence of a clear, well-defined pathological phenomenon. Cancer is not a disease. And neither is lymphoma. Hodgkin’s lymphoma, however, is closer to the mark. Why does this matter? Because a disease is a very specific entity, and one that is by-and-large understood. It’s specificity allows us to target very specific elements of the disease, to develop treatment. There are (almost) no diseases in psychiatry.
Syndromes, or disorders, are clusters of symptoms that tend to appear together and suggest to the observer (usually a physician) the type of problem which may be going on. For example, someone presenting to an emergency department with swollen legs, shortness of breath, and chest pain, likely has heart failure (a syndrome; heart failure with preserved ejection fraction may be the disease). We have many syndromes in psychiatry. Someone presenting with an inability to get out of bed, tearfulness, and suicidal thoughts, may have depression. Someone who hears voices and believes they are being monitored by the CIA may have psychosis.
So why the disconnect? Because the brain is cool.
The pathophysiology behind heart failure and lymphoma is relatively clear. This is not the case with mental illness. The human brain is extraordinarily complex, and is not easily studied under the microscope, or in labs with rats. It’s an exciting time in psychiatric research, as the human brain is in many ways considered the final frontier of medicine. For patients and individuals, it’s a frustrating time..
This ambiguity has caused us to rely on describing syndromes, as opposed to clear, well-defined diseases, in our practices. Syndromes, or disorders, can be seen all over psychiatry. Major Depressive Disorder. Generalized Anxiety Disorder. And I could go on.
Why is this important? A syndrome can be the result of a variety of things. Someone with chest pain, swollen legs, and shortness of breath, may also be having a heart attack. Someone presenting as depressed might have depression, bipolar disorder, hypothyroidism, or could be having a regular ol’ bad day. This helps explain why some people respond to medications, and why some do not. Why some people get great help from cognitive behavioural therapy, and others find it a waste of time. Since we’re dealing with a mixing pot of a variety of potential explanations, some trial and error is required as you and your doctor arrive at a suitable treatment. I get almost as frustrated as a patient when we are going through treatment and a medication doesn’t work, or a therapy isn’t suitable. It can be demoralizing to everybody involved. What can help is keeping in mind that that mystery and ambiguity are not unexpected, and are completely normal part of moving through the mental health system.
Dr. Travis Barron is a resident physician in the Department of Psychiatry at the University of Toronto in Toronto, Canada.