We're All Bozos on this Bus

“We do not have to visit a madhouse to find disordered minds; our planet is the mental institution of the universe.”                 ― Johann Wolfgang von Goethe

The truth is, we all have something.  At least that’s what I tell my patients. Not just because I want to normalize this for them, but because it’s true. Each of us falls somewhere on the spectrum of mental illness. It’s just the degree of dysfunction and impairment that our ‘something” occupies in our lives.
Thankfully, most people don’t experience their mental illness symptoms all the time. In other words, they aren’t always psychotic, manic, anxious or depressed. The symptoms usually cycle over hours, days, weeks, months or even years. Some are episodic. The illness is actually the “susceptibility or predisposition” to the psychosis or anxiety. Under the right biological and environmental conditions, the disease rears its ugly head.
Some people don’t have an official mental illness, but more of a personality disorder or abnormal temperament, which doesn’t make them mentally stable either, but rather places them in an outlier position on a bell curve. A milder form of mental illness if you will.
Don’t get me wrong, mental illness can be devastating, destructive, painful and terrifying. But it can also result in enhanced creativity such as during the alternating mood states in between cycles. Consider the brilliantly creative prodigious mind of a writer, playwright, composer, artist, or musician. There’s no question that some people dance gracefully between the blurred lines of genius and madness.
Because many symptoms of mental illness overlap with normal human emotional states, it becomes challenging sometimes to parse out the pathology from what’s inside the bell curve; the normal distribution of human emotions and behaviors.
Add to that the fact that some people who seek out mental health services may have co-morbid conditions (presence of one or more additional disorders), chronic illnesses or substance abuse. And may be taking medication for any or all of these, thereby exacerbating or creating new symptoms and side effects.
There seems to be a diagnosis for every imaginable human condition, problem or issue today. How do you know if you have a true mental disorder, or if it’s merely a variant of personality, a reaction to a drug or medicine, or an elevated response to a situation or event?
Psychiatrists and mental health clinicians obtain collateral information from various sources in order to provide a complete diagnosis and clinical picture. Many of you will have been diagnosed multiple times before an accurate diagnosis is made. Some of you may even receive a different diagnosis each time you see a psychiatrist or make a hospital visit. This is not so uncommon as many of these disorders share the same constellation of symptoms that ebb and flow through cycles.
Time is the biggest obstacle to obtaining a complete clinical picture, as many psychiatrists and clinicians are strapped with shorter and shorter intervals in which to see patients. It becomes virtually impossible to get a clear history of a patient’s symptoms in a short timeframe. Symptoms reported may be non-specific, exaggerated, or missed altogether. Family histories must be recollected and reported to the best of one’s ability.  Many report a family member having some such “odd behavior” but they don’t know the official diagnosis. The more severe disorders run in families and many have a genetic component to them. The course of illness must be discerned, starting when symptoms first appeared, whether they were episodic or continuous and if they were organic or attributed to medical conditions or drug use.  Most of the disorders have characteristic patterns and predictable trajectories. And finally, clinicians look at treatment history – what has worked for people in the past; what hasn’t worked. And whether or not the person has exhibited an unusual response to a drug, which may confirm a diagnosis or rule out others.
Sounds fairly straightforward. In theory yes, but in practice it can get convoluted quite quickly. Consider the patient who is not forthcoming with her symptoms, doesn’t recall having such symptoms, exaggerates or diminishes her symptoms or simply creates symptoms that don’t exist.
Sometimes they do this intentionally and other times they just don’t have insight into their state of mind to be able to articulate what they are feeling and thinking.
You can’t always trust that the person being assessed 1) does not have ancillary gains by reporting symptoms 2) understands what you are even asking or 3) is not denying symptoms because he fears being hospitalized or labeled crazy. 
Some may even “create” or magnify symptoms in order to get a hospital bed, medication, food and shelter for a few nights. Others may do it in order to receive or continue disability benefits.
Many people simply don’t remember when the symptoms started or how long they lasted. Or what medical condition or affliction they had at that time. Their perception of time and/or intensity of symptoms may have been skewed. What seemed like four months may have only been three weeks. They may not even recognize that they were ill, so coming up with a timetable and describing symptoms is often very difficult for them.
Many patients are reluctant to report symptoms that may be related to their substance use, such as psychosis, mania, or depression, which is usually the result of continued stimulant or synthetic drug use. This is understandable, but also very important to guiding treatment options.
So you see, there is no single source that is sufficient to diagnose a mental illness, but rather various sources that must be considered such as symptoms, genetics, course of illness and treatment.  And of course, all must be considered in the context of one’s culture and environment, and reported by a person with sufficient mental faculties, without ulterior motives or secondary gains or fear of perceived negative consequences.
An inexact science to be sure and the reason that so many people have multiple diagnoses over the course of their lifetime.
So…….. Hop on the bus. You’re in good company.