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Shadow Syndromes REPRINT

by John J. Ratey and Catherine Johnson


Neuropsychiatry is now discovering that a great deal of what we thought was due to (poor) upbringing in fact is heavily influenced by the genetics, structure, and neurochemistry of the brain. Every one of the troublesome personalities made famous by our popular press likely has its roots in an unsuspected brain difference: the Peter Pan syndrome, the Cinderella complex, the women who love too much, the men who can't love, the codependent--the list goes on. All of these people are doubtless going to turn out to have brain differences that contribute to their Peter Pan-ness or their Cinderella-ness or their codependentness. Of course, differences in the brain cut both ways: as studies of artists with manic-depressive illness have shown, a brain difference that handicaps us in one realm may also endow us with greater capacities in another. Our purpose in writing this book is not to pathologize every nook and cranny of everyday life, but to offer help for those areas in which our brain differences do hurt more than help. Until now there has been no biologically based help for the difficult personalities among us because no one has suspected that their problems might have biological facets.

That is the purpose of this book: to look again at the biology of everyday life one hundred years later--this time from the vantage point of twentieth-century neuropsychiatry. Our question in this book is: when we--or someone we love--are behaving at our worst, or simply behaving irrationally, what role does biology play? And: how do genuine problems in life, problems like a difficult childhood or a parent who drinks, interact with our biology to create the character traits and flaws that are not just written into our characters but into our neurons as well?

In order to take a second look at normal "craziness," we can learn from the kinds of craziness that are not so normal. When we speak of schizophrenia or severe manic-depression, there is no question in anyone's mind that the person is ill. And it is easy enough for us to believe that these illnesses are biological in origin (though it was not so long ago that these illnesses, too, were blamed upon bad parents).

The confusion begins when one sees patients who do not fit the classic categories, but who nevertheless have very real difficulties in life. Are these difficulties due entirely to upbringing and environment, or do they, too, have some basis in the brain's biology? Modern psychiatry has been struggling to make sense of these people for fifty years. Doctors diagnose their patients according to the syndromes described in DSM-IV, the Diagnostic and Statistical Manual, Fourth Edition. A syndrome is a set of behaviors that consistently appear together: a set of behaviors the patient, the doctor, or the patient's friends and family can observe and describe. A syndrome is not, at this point, a physical marker like the positive result on a test for HIV antibodies that establishes a diagnosis of HIV-positive. When a psychiatrist diagnoses the syndrome of panic disorder, for example, he cannot--yet--perform an MRI (magnetic resonance imaging) that tells him whether the patient does or does not qualify for the diagnosis (although we may be closest to such a test for this particular disorder). Instead, he looks for symptoms: a pounding chest, rapid heartbeat, shortness of breath or hyperventilation, sweating or coldness and changes in temperature regulation, the fear that one is having a heart attack, sometimes a feeling that the person is going to pass out, sometimes a feeling that he or she is going to go crazy. This is the set of symptoms that make up the syndrome.

The problem is, every patient is different--including every patient with the same diagnosis. As a result, the number of syndromes recognized by practicing psychiatrists has leapt in the forty years since the first edition of the DSM appeared in 1952. That volume described 60 categories of abnormal behavior. DSM-II, published in 1968, more than doubled this number to 145 syndromes, and DSM-III raised the total to 230. The DSM-IV, which appeared in 1994, lists 382 distinct diagnoses, plus an additional 28 floating, or unassigned, diagnoses--which brings us today to a total of 410 different possible diagnostic labels. What the ever-increasing number of possible diagnoses means is that a person who comes into a psychiatrist's office complaining of being depressed, for example, could be categorized as belonging to one of four major categories--bipolar disorder, major depression, "other specific affective disorders," or "atypical affective disorder"--with several subcategories included within each of these main categories. (A patient diagnosed as bipolar could then be further characterized as "mixed," "manic," or "depressed," for instance.) It is a complex business.

As time goes by, we find that the art of diagnosis grows ever more fragmented; seemingly sound diagnostic categories keep breaking down. Emotional problems do not fit the "concrete blocks" of the DSM-I, -II, -III, or -IV; real people come into the office with bits of this and pieces of that. A patient might show signs of panic disorder, signs of major depressive disorder, and signs of a narcissistic personality disorder all in the same package. He or she may have parts of a whole array of syndromes, and yet not suffer from all of the symptoms of any one syndrome. Or he may fit every aspect of a syndrome down to the smallest detail and yet be so mildly affected compared to other people suffering from that problem that even a good therapist might miss the diagnosis. Finally, a patient may exhibit only one or two symptoms from a particular syndrome, a condition long known as a forme fruste in conventional medicine. A patient with a forme fruste of Graves disease, for instance, might have the bulging eyes without the sweaty hands, rapid heartbeat, irritability, and weight loss that accompany a full-blown case of the illness. A forme fruste is an incomplete expression of an illness, though the term is little used today. We have chosen to replace it here with the phrase shadow syndrome because the meanings of the word shadow, both literal and metaphorical, capture the nature of a mild mental disorder. In the literal sense, a shadow is an indistinct form of something all too vivid and real, just as a shadow syndrome is an indistinct and seldom obvious form of a severe disorder. And metaphorical shadows cast a pall across a day that might otherwise be sunny and clear. This is what shadow syndromes do in the realms of work and love: they cast a shadow.

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