Comorbidity: Missing The Wood For The Trees?
Comorbidity, sometimes called dual-diagnosis, is the term used when a person presents with the symptoms of more than one condition. For example: depression and obesity, anxiety and high-blood pressure, depression and anxiety, or trauma and addiction. A concern for people both experiencing the symptoms and seeking to help or treat mental illness, is that the symptoms of one condition might make the symptoms of another condition worse.
So if a person experiences high-anxiety and IBS, the stress hormone cortisol can trigger IBS symptoms. Likewise, a person may develop an addiction to a depressant substance, like alcohol, cannabis or opioids, as a result of self-medicating against the symptoms of post-traumatic stress disorder (PTSD), like distressing thoughts or memories.
People who suffer with obesity may have low self-esteem about body image, which may cause low mood and worry, raise levels of stress hormones, which affects how they metabolise food and result in further weight gain. As we can see, comorbidity can be a case of which came first, chicken or egg.
Many clinicians find it helpful to think about mental health conditions as separate illnesses because it aids diagnosis. Looked at this way, depression is seen as distinct from anxiety, which is distinct from phobias, and so on. If they are working from a medical model in this way, they may want to identify which medications should be prescribed, and will refer to listed criteria, perhaps in the Diagnostic Statisticians Manual IV, or DSM-IV, currently in its 5th edition.
This approach views mental illness as specific and distinct constructs. The first edition of the DSM, published in 1952, listed 128 different conditions, while in the current 5th edition this list has grown to 297!
Of course, these labels may not reflect a person’s experience of mental ill health. In practice, it is very common for a person to experience the symptoms of depression and the symptoms of anxiety alongside each other. And for this reason a person may be given diagnoses of both anxiety and depression and medication for both.
There is a very old story which describes how an injured eagle landed on somebody’s windowsill. The person, who had never seen an eagle before, took the eagle in and looked after it until it was better. Before releasing the eagle into the wild, they clipped its wings and talons and exclaimed, “There! Now you look like a proper woodpigeon!”
One of the many meanings of this story is that people – or birds – don’t always fit into neat and tidy boxes. So focusing on the symptoms and ignoring the problems in a person’s life might prevent us from solving problems which cause the symptoms. Insisting that people match diagnostic criteria and labels can cause us to miss the person and the valuable skills and experience which can be drawn upon to support their recovery. If we encourage people to dwell on their problems it can make their symptoms worse. If we believe that all mental ill health is caused by either genes or society, when the evidence is clear that environment and genes are always interacting, then our beliefs may be a barrier to learning how to address mental ill health.
So is there a way of looking at mental health which goes beyond labels? At Suffolk Mind we think that there is. At the heart of Suffolk Mind’s work are some powerful organizing ideas which help to think more clearly about mental health. The first of these is the mental health continuum.
Instead of looking at mental health conditions as separate diagnoses, the mental health continuum sees mental health as running from a state of mental well-being at one end, to severe mental ill health conditions like psychotic illnesses, schizophrenia, bipolar and so on, at the other. We are all on the mental health continuum and move up and down it throughout the course of our lives.
Stress is the threshold or crossover point between mental well-being and mild to moderate anxiety and/or depression, and stress triggers the symptoms of existing conditions which people might be managing or recovering from. And stress is not random. Stress is nature’s way of telling us that an important emotional need is not met and needs addressing.
This could be a need for security; to have control over the direction of our lives; to give and receive attention; to have status and feel valued; to feel connected to the wider community; to share a close emotional connection with someone – or a pet! – that we can rely upon; to feel stretched and challenged; and to feel that our lives have a sense of meaning.
When we focus on working with a person to get needs met we are focusing on the real person, and diagnostic labels, comorbid or otherwise, become less significant than the person behind them.