Joey Wahler (Host): They can be confusing at times to patients. So, we're discussing mental health diagnoses. Our guest is Dr. Awais Aftab. He's a psychiatrist. This is Southwest General Health Talk, the podcast from the specialists at Southwest General Health Center. Thanks so much for joining us. I'm Joey Wahler. Hi there, Doctor. Welcome.

Awais Aftab, MD: Hi.

Host: Great to have you aboard. We appreciate the time. This is an interesting topic, right? Because many people come into a mental health appointment wanting to know, "What do I have?" if you will, "What's going on with me in terms of mental health?" So, why is that question so important to patients? They want to boil it right down, and that's not always so easy, right?

Awais Aftab, MD: Yeah, exactly. I mean, it's very understandable. People want to know what's wrong, what's going on, what's the nature of the problem. And I think it's the language here that can be potentially misleading. So when people say what they have, you know, they might have in their minds, you know, something similar to diagnosing a genetic mutation or something similar to diagnosing kind of like, you know, identifying a bacterium or some other kind of, let's say, autoimmune chain. So, there's this idea that there is a specific malfunction or dysfunction in the body that can be identified.

The mental health problems, you know, don't really work that way. So, you cannot peer into the body and find the localized abnormality, but rather these are problems at the behavioral level. And the way they are diagnosed, we look at overall patterns of symptoms and clinical features. So oftentimes when patients say, "Do I have ADHD?" or, "Do I have autism?" or, "Do I have anxiety?", we need to have a discussion regarding what that have implies.

Host: And speaking of which, to pick up on that, when someone receives a diagnosis like anxiety, depression, ADHD, bipolar disorder, some of the more common things you deal with, what does that diagnosis actually tell you and them? Because it seems like what you just said in a nutshell is that that's not the whole story, right?

Awais Aftab, MD: Yes. Yeah. Because scientifically speaking, our understanding of mental health problem is still in early stages, so we define psychiatric problems and mental health problems in terms of their superficial features, in terms of their behavioral manifestations, as well as self-reported difficulties.

And when we're making a psychiatric diagnosis, what we are doing is that we are comparing a particular patient's, you know, presentation, their overall picture with different kinds of textbook descriptions that we have and that have been formalized and operationalized in diagnostic manuals like the DSM.

So, we have a certain idea of what clinical depression looks like or is supposed to look like. We have a certain idea of what the cluster of generalized anxiety looks like. We have a certain idea of what the cluster of attentional difficulties and hyperactivity we call ADHD looks like. And so, psychiatrists, they're trying to match the presentation of the patient in front of them with various different clusters that we have identified and described in research studies and in textbooks. And we make a kind of judgment call that this presentation is a good fit with this textbook description that we have.

But because these descriptions come with fuzzy boundaries and they often overlap, it becomes a judgment call. And this is something that, you know, we can get wrong if we don't have the right kind of information in front of us. And this is also something that could be revised over time.

Host: And so, I would imagine you therefore, Doctor, often need to explain to patients, "Hey, this is not as clear-cut a diagnosis as in other areas of medicine." There's more of an air of mystery or at least trial and error to it, right?

Awais Aftab, MD: Yes. Yeah, completely. I think things are not as straightforward and not as clear cut. And this primarily has to do with the fact that we don't have an objective anchor or we don't have a physical anchor, you know, as we do in many other conditions. So now, it is very common in general medicine too, for things to exist on a spectrum or things to be graded or things to have fuzzy boundaries.

You know, like take obesity, you know, like, we have weight, but weight is a spectrum. We use certain, you know, somewhat semi-arbitrary thresholds or take, you know, hypertension. You know, you can dispute what exact thresholds you want to use. And so, similarly, mental health problems also exist on a spectrum. And there's this question of where to draw that threshold. But the additional difficulty is that unlike things like obesity, unlike things like hypertension, we are relying on self-reported features and we are relying on behavioral features, and we don't have a precise physical marker or physical anchor, which just kind of like means that there is greater room for error and our confidence in these things sometimes can be lower.

Host: And so, when you're explaining that to a patient, how do you do so, so that the diagnosis is helpful to them without becoming the way they define themselves? How do you get that point across?

Awais Aftab, MD: Yeah. So, I tend to explain the diagnosis as being practical tools. This is something that helps us make sense of the current presentation and the current problem, and it helps us connect the problem with the larger body of scientific knowledge and medical knowledge that we have about that sort of problem and how to address it.

But we should not mistake that label as describing the nature of the problem itself or providing us with answers regarding what the mechanisms are or what the processes are. And we have to keep in mind that this label may not prove as fixed or as stable as we may, you know, initially anticipate it to be. So, we have to hold the diagnosis or the label lightly, and try to keep the overall picture of, you know, mental health functioning and the life environment and, you know, all of that in mind.

Host: And another big inherent difference between a mental health diagnosis and one in other areas of medicine, again, just making that comparison, is the fact, am I right, that two people might have the same mental health diagnosis but very different symptoms, challenges, or treatment options, right?

Awais Aftab, MD: Yes. Yeah. There a considerable kind of variation in how these kind of diagnosis can present. Now, variability is pretty common in medicine too in many diagnosis. I mean, you know, if let's say someone has, you know, COVID-19 infection, one person could have very mild symptoms, you know, other person could, you know, have very severe complications, could end up in the hospital, right? So, even in medicine, there's a lot of variability. But there's something that unifies those diagnosis at the physical abnormality level, we're able to kind of tie it together.

When it comes to mental health problems, the difficulty of the variability gets compounded. Because, you know, aside from the behavioral similarities, we are not certain what it is that is common between them. So if one person, let's say, is depressed and they can barely get out of the bed, they're physically depleted, they can barely eat. And then, we have another person and, you know, they're active. In fact, they're somewhat agitated. They're a little emotionally agitated. They're highly anxious. They're highly stressed, right? And so, we have two very different sorts of depression at play here. And, you know, because our understanding of the mechanisms involved is very limited, we don't know what, if anything, that they share, you know, beyond the commonalities of mood.

Host: So, you gave a great illustration there, doctor, the fact that two people could have anxiety, depression. Some may be more withdrawn, others become more agitated, aggressive, et cetera. How about the fact that mental health symptoms do change over time very often, right? Or fit different diagnoses at various points in a person's life. Tell us about that.

Awais Aftab, MD: Yes. We have developed a better appreciation of the change in mental health symptoms over time. There's new thinking in the mental health field. There's an approach known as clinical staging. And the idea is that just as many physical health problems develop through identifiable stages, you know, think of cancer, you know, there's pre-cancerous stage, there's stage I, stage II, stage III.

You know, if you think of diabetes, it evolves through stages. There's insulin resistance and pre-diabetes, diabetes. So, there's a similar idea that mental health problems are also evolving through these stages. And this is particularly relevant early on in life, in adolescence, in young adults, because that's when a lot of mental health challenges begin.

And the crucial kind of point of the clinical staging approach is that in the beginning, in stage I and kind of, you know, early kind of sub-threshold features, problems often present in a kind of fuzzy, fluid, and ambiguous kind of manner. Patients present with a mix of different types of symptoms that don't fit classic textbook presentations.

And those early mix of symptoms, they have the potential to develop into different directions. So if we have let's say a 14-year-old teenager who is presenting with anxiety symptoms, that does not mean that they're going to develop an anxiety disorder, but rather that early anxiety could be a marker for a later depressive disorder or for a later substance use disorder or for a later psychotic disorder.

So, we have to keep the non-specific nature of symptoms in mind when we're looking at adolescents and young adults, and we have to recognize that these things are in an evolution and the exact symptom mix we are seeing right now, it is likely to change. And the kind of more, relatively more stable pattern of mental health difficulties might only become obvious, you know, a couple of years later.

Host: Couple of other questions for you. First, this is interesting. You've written about symptoms sometimes reinforcing one another. Sleep problems feeding anxiety, isolation worsening depression. So, it's almost like some people suffer from a Noah's Ark of psychiatry, right? These things come in twos. So, can you explain in a nutshell for the layperson like myself how that cycle can take place where those things feed into one another?

Awais Aftab, MD: Yes. So, this arises from a theoretical approach in mental health field called network theory. And the basic idea is that different symptoms of mental health, they're not independent of each other. They not disconnected, but rather they connect with each other, they reinforce each other to form a broader overall pattern or a network. So, you can think of it this way. Let's say a person is experiencing a lot of stress in their life and because of that stress, they start having initially sleep difficulties. Because of those sleep difficulties, now they're experiencing tiredness during the day. They are more fatigued. That tiredness begins to pull on their mood, and now they're experiencing low mood. And that low mood is now affecting their thinking, and they're looking at things from a more negative perspective. And that is generating restlessness and that is generating worry. And that worry begins to feed into their sleeping difficulties. And that feeding difficulty again worsens the daytime tiredness, that worsens mood.

So, it becomes a self-reinforcing loop. And all of the symptoms, they are feeding into each other and keeping that depressive cycle alive, such that even if the social difficulties or the life difficulties that started the whole cycle, they are now resolved. They are gone. Life is okay. But that cycle has become self-sustaining, and the person has become stuck in this depression anxiety loop that they cannot get out of.

Host: And then, in summary here, what would you say to someone joining us right now who feels either confused by a mental health diagnosis, perhaps has received multiple such diagnoses, or maybe worries that a label they've been presented with doesn't fully explain what they're experiencing? Maybe they're like, "I still don't have an answer here." How do you deal with that? Or I would imagine, am I right, that part of it is you've got to keep working toward it, yes?

Awais Aftab, MD: Yes. Yeah. I think the basic challenge here is that mental health problems, they're highly complicated, multifaceted phenomena. They have multiple dimensions, and they can be looked at and analyzed from many different angles. We often rely on mental health diagnoses, which are formal ways of describing the patterns of symptoms and, you know, that people have and the kind of clusters those symptoms form.

But we also have to look at the psychological dynamics behind those symptoms. We also have to look at the life conditions and the developmental history that is driving those symptoms. So, a formal diagnosis or a label is just one part of a bigger picture, and we have to look at these problems from many different angles, which is why we use medications, but we also use things like psychotherapy, and we use things like neurostimulation, and we work with patients in developing a comprehensive formulation of these problems.

Host: Well, folks, we trust you're now more familiar with mental health diagnoses. Doctor, keep up all your great work. Thanks so much again.

Awais Aftab, MD: Thanks for having me.

Host: Absolutely. And for more information, please do visit swgeneral.com. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks again for being part of Southwest General Health Talk, the podcast from the specialists at Southwest General Health Center.