FADS AND OVER-DIAGNOSIS
Over the past several decades psychiatric diagnostic acumen has improved significantly. However, more and more people seem to carry psychiatric diagnoses that are inaccurate and have negative consequences. Additionally, it seems that fads in psychiatric diagnosis come and go. Likely they satisfy a deep-felt need to explain, or at least label, unexplainable human deviance. In recent years, the pace has accelerated and false ‘epidemics’ have come to involve an increasing proportion of the population. We are now in the midst of at least three such epidemics – autism, attention deficit disorder & childhood bipolar disorder. Estimates suggest that in any given year, 25% of the population (almost 60 million people) has a diagnosable mental disorder. A study showed that, by age thirty-two, 50% of the general population will ‘qualified’ for an anxiety disorder and 40% for depression. Imagine what the percentages will be by the time these people hit fifty, or sixty-five or eighty? In this brave new world of psychiatric over-diagnosis, will anyone get through life without a mental disorder?
What accounts for the upsurge in diagnosis? It is unlikely that we can blame it on our brains. Human physiology changes very slowly. Could it be caused by our stressful society? There is no good reason to believe that life is any harder now than in the past. It is more likely we are a more pampered and protected generation than ever before. Most likely that these ‘epidemics’ are caused by changing diagnostic fashions – in other words, people don’t change, the labels do. There are no objective tests in psychiatry – no X-ray, laboratory, or exam finding – that say definitively that someone does or does not have a mental disorder. Other factors contributing to the increase include:
1) DSM manuals being sold to more ‘ordinary’ people than to mental health professions. This has made psychiatric diagnosis accessible to the general public, allowing self-diagnosis.
2) Definitional thresholds may be set too low. We seem to worry more about missing cases than about casting too wide a net and capturing people who do not require a diagnosis.
3) The pharmaceutical industry over-utilizes marketing. Drug companies are skilled at mounting a full court press that includes ‘educating’ doctors, ‘supporting’ advocacy groups, controlling research, and direct-to-the-consumer advertising.
4) Patient and family advocacy groups call attention to neglected needs (lobbying for clinical, school, and research programs; reducing stigma; and promoting group and community support). Advocating for those with a disorder can spill-over and promote the spread of the disorder to others who are mislabeled.
5) Recent ‘epidemics’ have occurred mostly in childhood disorders. Perhaps a contributing factor is that the provision of special educational services often requires a DSM diagnosis?
6) The internet provides a wealth of information and creates a network of ‘informed consumers’. Disorder-focused web-sites provide an attractive forum & support system that draws people who inaccurately self ‘over-diagnose’.
7) The media both feeds off of and feeds public interest. It is not uncommon for the media to become obsessed with one or another celebrity whose public meltdown seems related to a real or imagined mental disorder. An example is the Tiger Woods media frenzy which will likely lead to an ‘epidemic’ of sexual addiction. Popular movies can also be contagious: Sybil helped cause a fad in multiple personality disorder.
8) We live in a society that is intolerant of normal individual difference. What was once accepted as aches and pains of everyday life is now labeled a mental disorder. Eccentrics who would have been accepted on their own terms are now labeled Asperger’s and in need of intervention. Criminal behavior has been medicalized (rape as a psychiatric disorder) because prison sentences are too short and such labeling allows for indefinite psychiatric commitment.
Despite all this uncertainty about diagnosis of mental health disorders, a few certainties exist. There is sufficient research to indicate that a significant subset of people diagnosed with mental health disorders, in fact, have hormone imbalances. The connections between hormones and the brain is undeniable. Hormones impact brain chemistry and circuitry, and hence influence emotions, mood and behavior.
For many adolescents, the first exposure to the mood-changing impact of hormones is puberty. Pubertal girls and boys can experience significant upheaval due to constant emotional ups and downs, irritability, depression, anxiety, brain fog, and moodiness. Boys can have additional symptoms of anger with rising and fluctuating testosterone. At the beginning of puberty, the brain releases GnRH, which triggers secretion of FSH and LH. In girls, FSH and LH instruct the ovaries to begin producing estrogen. In boys, the same hormones initiate production of testosterone. Many of the mood swings that teens experience are caused by fluctuations in these hormones. These same teen hormones will also affect the way they think about dating and sex. Teens become more interested in sex, sometimes to the point of obsession, as hormones kick into gear. Many adolescents feel that these hormone-related changes are weird or unnatural.
In adolescent girls, hormonal disorders are often overlooked because we tend to focus on the time they begin menstruating. We forget that long before a girl undergoes menarche, a variety of other changes occur that commence with hormone fluctuations: thelarche (breast development), pubarche (pubic hair growth), and the pubertal growth spurt. In considering anger, mood swings, and changes in behavior, we must consider their relationship to these other hormone-mediated events.
PREMENSTRUAL SYNDROME (PMS) AND PREMENSTRUAL DYSPHORIC DISORDER (PMDD)
PMS affects up to 85% of women. Irritability, tension, and dysphoria are the most consistently described symptoms. Women whose affective symptoms are especially severe may meet criteria for PMDD, which occurs in 2-10% of women. PMDD is a serious, disabling condition that can rob a woman of her functioning every month. PMS and PMDD are cyclical, with symptoms arising during the luteal phase of the menstrual cycle and lasting until the onset of menstrual flow. Prior to ovulation, estrogen rises, while during the luteal phase following ovulation, progesterone rises. Immediately before the onset of menstruation, estrogen and progesterone both decrease. The tricky part about PMS and PMDD is that they are not always exactly the week before bleeding, nor do they last exactly a week. It is further complicated in women who do not have the ‘classic’ 28-day cycle.
Arguably the most frequent, popular and incorrect diagnose associated with puberty is bipolar disorder, in all of its subtypes and flavors. It seems that any adolescent who is moody, angry, or temperamental is labeled bipolar. Bipolar disorder and PMS/PMDD have many similar symptoms. Both are characterized by cycling moods, including severe depression. There are hundreds, if not thousands, of adolescents running around with this diagnosis, yet many of them have never had a manic episode, which is the hallmark of bipolar disorder. Many of these kids have never had anything other than irritability. Load them up with cocktails of anxiolytics, antidepressants or medications like Seroquel, Depakote, Abilify, Lithium, Klonopin & Trazadone and their symptoms go away. The proof is NOT in the pudding. All that is proven is that one’s affect can be obliterated by harsh medication cocktails. But being incapacitated by medications does not prove bipolarity. This confusion is tragic because these therapies are often ineffective and more damaging, with serious long-term side effects in the form of obesity, metabolic syndrome, diabetes, sexual dysfunction & movement disorders.
After careful evaluation and consideration, these patients need to be detoxified from their toxic cocktails. Once these medications have worn off, consider a tailored titration onto a pulse pattern of a SSRI or Wellbutrin to control the PMS. Sometimes Monoamine Oxidase Inhibitors (MAOI’s) are used because it is the surge in MAO that occurs abruptly when a woman’s estrogen drops. The MAO is the enzyme that degrades all biogenic amines – dopamine, serotonin, norepinephrine, etc. and induces the moodiness and symptoms of PMS/PMDD. These patients should also be started on therapies designed to suppress cyclical hormonal changes (suppress ovulation). Longstanding ‘bipolar depression’ often disappears when the premenstrual cycle is suppressed.
POLYCYSTIC OVARIAN SYNDROME (PCOS)
The subset of girls who will eventually be diagnosed with PCOS creates an even bigger set-up for misdiagnosis. Most PCOS patients are diagnosed after menarche – in other words, adolescents diagnosed with mental health disorders, who have PCOS, often haven’t been diagnosed with PCOS yet. PCOS is characterized by irregular menses, elevated testosterones, masculinization, hirsutism, weight gain, metabolic disturbances and many other features. These patients have significant hormone fluctuations without a menstrual cycle. They have florid mood swings, affective dysregulation, depression, impulsivity, suicidal gestures…the whole gamut. True psychotic symptoms are rare. Most mood medications these girls are started on cause weight gain and some directly increase blood glucose and all of this is quite bad for a PCOS patient.
PREGNANCY AND POSTPARTUM
Pregnancy and postpartum are other key times when mind and hormones intersect. Some women have their first experience with significant moodiness, emotional ups and downs, and frank depression during or after pregnancy. Postnatal depression and psychosis are key mental illnesses that have a major hormonal component to their onset and course. This is thought to be triggered by the sudden, rapid drop in the high levels of pregnancy hormones shortly after birth.
The next commonly recognized — but not well-understood — time, is broadly referred to as ‘menopause’. Broadly, because the term isn’t really used properly. Menopause is a single moment in time when a woman has not had a period for a full year. In the United States, the average age is 51. But most symptoms associated with menopause — erratic periods, hot flashes, mood swings, sleep disturbances, mental fog and decreasing mental focus, weight redistribution, decreasing motivation, diminished exercise endurance, muscle & joint aches, diminished exercise recovery, headaches, and changes in sex drive— take place during perimenopause — the time before menopause — when testosterone, estrogen and progesterone can go up and down erratically. These fluctuations can actually start as early as late thirties. During this transition, women experience major hormonal shifts. During this time, women are 14 times more likely to experience depression. It affects women differently than other types of depression, causing anger, irritability, poor concentration, memory difficulties, low self-esteem, poor sleep and weight gain. Perimenopausal depression isn’t well recognized and is often poorly treated with standard antidepressants. Women with this type of depression respond better to hormone treatments.
Diagnosis of hormone-responsive depression should be made through the patient’s history and not through the measurement of hormonal levels, since hormonal levels in premenopausal women are typically normal. Instead, carefully consider the patient’s history that point to hormonally based depression.
- A history of mild or severe PMS as a teenager
- Relief of depressive symptoms during pregnancy
- Postpartum depression, with new-onset or newly recurring depressive symptoms
- Recurrence of premenstrual depression following resumption of menstruation after delivery
- Worsening of premenstrual depression with age, blending into the menopausal transition and becoming less cyclical thereafter
- Coexistence of cyclical somatic symptoms, such as menstrual migraine, bloating, or mastalgia, which are not associated with bipolar disorder
- Runs of 5 to 20 euthymic days per month
- Recurrent episodes of depression, often severe and related to menstrual periods, but without episodes of mania
Beyond the patient’s personal history, family history can shed light on the origin of depressive symptoms. If the mother and sisters also suffer from PMS and postnatal depression, it can be suggestive of a familial hormonal basis for the symptoms. Alternatively, a history of bipolar disorder and suicide in male relatives would suggest mixed etiology.
MEN & HORMONES
Low testosterone leads to andropause, which can result in erectile problems, diminished libido, decreased muscle strength and decreased bone mass. To complicate matters, testosterone is converted to estradiol in men (via aromatase enzyme). So, testosterone exerts its effects independently (as itself) and indirectly via conversion to estrogen. Too much estrogen can lead to excess breast tissue, depression or mood swings. Too little estrogen contributes to mood disturbances, low sex drive, decreased motivation and diminished ability to retain muscle mass. Fluctuating estrogen levels, also cause mood swings, which further complicate the picture. A discernable PMS pattern of behavior is often recognized with these fluctuations. If all this wasn’t complicated enough, the relationship between E and T is also very important, especially with regard to mood changes. Altered estrogen/testosterone ratio (both too high and too low) can cause problems with memory function, depression, irritability, sleep, fatigue and occasionally even hot flashes/sweats.
After seeing a series of men diagnosed with a putative mental health disorder, prescribed all of the usual drugs, there is a discernable pattern of diminished libido, sexual dysfunction, subtle feminization and new/strange sexual thoughts & fantasies. Initially, these were considered medication side effects. However, evaluation of hormone levels indicates relative to absolute hypogonadism. Furthermore, these findings are not attributable to psychiatric drugs because this phenomenon is also seen in men who present with similar complaints and no prior treatment with these mood medications. In addition to having low testosterone levels, these men often have high normal or abnormal estrogen levels. If these men are weaned off mood medications and started on testosterone replacement, their moodiness, irritability, insomnia and other symptoms resolve as they are re-masculinized & estrogen levels fall.
When considering testosterone replacement in men, avoid topical preparations (when possible) if concerned about increased conversion of testosterone into estrogen. The enzyme that coverts testosterone into estrogen is found in increased quantities in adipose tissue. Use of injectable long-acting, slow-release testosterone works best for these men.
OTHER HORMONES INVOLVED IN MOOD
In addition to our male & female hormones, there are other hormonal imbalances that can have profound effects on mood.
Thyroid issues are an often overlooked, hormonally-triggered cause of symptoms. When the thyroid becomes overactive – hyperthyroidism — symptoms can include anxiety, insomnia, moodiness, panic attacks, and depression. Some men and women have even been mistakenly misdiagnosed as having panic disorder or anorexia, before properly diagnosed with an overactive thyroid. An underactive thyroid — hypothyroidism — can cause depression, moodiness, fatigue, and anxiety.
While conventional doctors often rush to prescribe antidepressants, it is essential to routinely check patients for thyroid imbalances prior to prescribing any medication for depression or other mood disorders. Interestingly, one symptom of undiagnosed hypothyroidism is depression that does not respond to antidepressant therapy. Thyroid problems are also more likely to show up during periods of hormonal flux – puberty, pregnancy, post-partum, perimenopause, menopause and andropause — which makes it even more important to have a full thyroid evaluation done if you experience depression or anxiety during these times of life.
Adrenal issues — imbalances in the body’s stress hormones adrenaline and cortisol, and the precursor hormone DHEA — can cause a variety of symptoms that seem to be mental health-related, including depression, anxiety, and insomnia. In patients that have experienced trauma or violence, chronically elevated levels of cortisol can result, causing significant mental illness at any time in a person’s life. High cortisol levels have huge impacts on many brain regions, resulting in rage, suicidal thoughts, obesity & infertility. A chronic excess of stress hormones can make you feel jittery, anxious, unable to sleep, and irritable. A chronic deficiency of stress hormones can make you feel sluggish, tired (even after sleep), moody, depressed, and have difficulty concentrating. Daily fluctuations and imbalances can cause a mix of these symptoms.
Hormone replacement is also often part of the transition process for transgender patients. This is, yet, another area where hormones and mood intersect. Many transgender patients experience dysphoria, or psychological distress due to the discrepancy between the sex they were assigned at birth and their gender identity. There is a high prevalence of depression, anxiety & suicidal thoughts.
Hormones help align physical characteristics with gender identity. Many individuals report hormone therapy is extremely beneficial because it enables them to maintain a physical appearance that more closely matches their gender identity, thus increasing their comfort with their physical appearance and decreasing dysphoria & distress. The effects on physical characteristics from HRT can usually be seen in one to three years, but a person receiving hormones will continue taking them for the rest of their life in order to maintain the effects. Research shows that HRT significantly reduces depression, anxiety, and sensitivity, along with feelings of hostility. Additionally, HRT often has the effect of increasing self-esteem and feelings of attractiveness. During gender transition, people who receive hormones typically experience a second puberty, during which secondary sex characteristics change to align with gender identity.
Trans-women receive estrogen in addition to antiandrogens to block testosterone. Trans-men take testosterone, which stops the menstrual cycle, lowers voice, and facilitates facial hair growth, though there may be other effects as well. Non-binary individuals (those whose gender is not specifically male or female) take hormones to produce characteristics that align with their identity or eliminate characteristics causing distress/dysphoria.
It is essential to remember that it is not possible to choose which characteristics result from HRT, and hormone therapy will affect people in different ways. Because of this, the initiation of hormone replacement can also increase feelings of dysphoria and distress. Many transgender patients don’t quite know what to expect. Often the changes in hormones they experience from replacement do not yield results that they anticipated or have side effects that were not considered. For the reason, it is essential to counsel these patients thoroughly before initiating a regimen.
THE TAKE HOME MESSAGE
Before you go down the road of antidepressants and/or anti-anxiety medications, make sure you take a complete medical history, assess symptoms, do a thorough clinical exam, and run comprehensive blood testing to evaluate and diagnose any hormone balances. Unlike most medications and supplements that support and balance hormones, antidepressants and anti-anxiety medications often have significant side effects, and frequently don’t even resolve your symptoms if the underlying cause is a hormonal issue.