BEHAVIORAL HEALTH
The P Factor A new framework for assessing mental health BY BRENT NELSON, MD
F
inding ways for accurate and consistent diagnosis in mental health has been sought since the emergence of self-awareness. For millennia we have struggled to understand who we are and how our internal experience matches with the reality of the external world. We work to describe the complexity of this experience so others can relate, understand, and interact. At times, our internal state or interactions with the external world do not match our expectations, which becomes distressing. This can lead to dysphoria and to cycles and behaviors we consider abnormal. We seek out care in the hope of understanding and intervention, with the goal of improved feelings and a return to health. This is the practice of psychiatry and medicine in general.
History The practice of medicine has evolved over thousands of years, driven by a welldefined process of description, measurement, diagnosis, and intervention. Over time, science has sought to establish systems to standardize the description of disease and identify potential solutions or treatments. This is especially true regarding the subjective nature of the dysphoria described above. Chinese
historical records dating back to 1100 BCE show motivation for the classification of mental health problems. These records included detailed observations of behaviors and emotions, grouping them into categories for study and treatment. The ancient Greeks attempted to explain possible causes of notable afflictions with the goal of testing ways of healing them. Kraepelin, Bleuler, and Freud all crafted theories around symptom clusters and drives. These explanations were guided by our early, and sometimes erroneous, understanding of neurology and the brain. These pioneers were left feeling an incomplete understanding of the system and knew there were still many missing pieces of the puzzle.
The DSM and its limitations In 1952, the American Psychiatric Association developed the Diagnostic and Statistical Manual of Mental Disorders (DSM). This groundbreaking manual harkened back to the work done in 1100 BCE to offer a taxonomy of symptoms grouped into diagnoses. The goal was to provide a common language for describing various mental health presentations in order to provide specificity for clinical care and future scientific discovery. While highly successful in clinical care, it was well-known that, despite the DSM’s taxonomy and descriptions of multiple symptoms, the manual does not necessarily reflect groupings of underlying neuropathophysiology. A simple example: not all sadness is vegetative depression, just as not all chest pain is myocardial infarction. Studies of the DSM also reported significant overlap between different diagnoses, leading to ambiguity and potential misidentification of an illness, as well as to subsequent misapplication of a treatment. A study by Newmann et al. in the Journal of Abnormal Psychology proposed a “rule of 50%,” which states that half of individuals who meet diagnostic criteria for one disorder also meet criteria for a second disorder. For example, anti-NMDA receptor encephalitis was classically diagnosed as schizophrenia, but now, due to advanced diagnostic techniques, is recognized as an auto-immune disorder that manifests as psychosis. Another example is the childhood spectrum of disorders called PANDAS, which were often labeled as obsessive-compulsive disorder but are now are also thought to be related to strep infections and a possible autoimmune connection. While the symptoms of both of these disorders are consistent with the DSM’s descriptions, underlying etiology is developing clarity in some of the “OCD” disorders and not others, likely because they are different disorders, even though the symptoms are similar.
COLLABORATIVE SOLUTIONS. INSPIRED DESIGN. The LEO A DALY team brings a passion for designing spaces focused on the human experience. Elizabeth Schulze, AIA, LEED AP BD+C Healthcare Market Sector Leader EOSchulze@leoadaly.com • 612.752.8733
18
JULY 2020 MINNESOTA PHYSICIAN
Providers clearly recognized a need for more precision in not only our language, but also our understanding of underlying physiology.
Comparisons to medicine Historically, the successful practice of medicine has been dependent on the sophistication of the tools available. In some areas of medicine, problems can be described and measured easily due to their macroscopic nature. This allows for development of a reliable mechanistic understanding, which then leads to a clear rubric of steps required to address the problem. Other areas are based on microscopic findings. These topics are less visible initially, but as high-resolution
