The Secret Language of Doctors

by Brian Goldman

  Part of the problem is that, unlike cardiology or orthopedic surgery, psychiatry is a relatively new field of study. It’s got some catching up to do, says Robert Klitzman, a psychiatrist and bioethicist at Columbia University Medical Center in New York City. Klitzman is the author of several books, including A House of Dreams and Glass: Becoming a Psychiatrist and When Doctors Become Patients.

  “It’s much harder to study autism, schizophrenia, depression, bipolar affective disorder and anxiety disorder than kidney or bone disorders,” says Klitzman. “We don’t know as much about how these disorders work on a physiological level. The science is moving along rapidly but is not as advanced as other areas in which it’s easier to intervene.”

  It’s the absence of hard science that makes it easier to denigrate the field of psychiatry.

  “When we say ‘non-organic,’ we immediately delegitimatize that disease as a real thing,” Quinn says. “And it becomes very stigmatizing because even the language of medicine says it’s a non-organic disease and therefore not a real disease.”

  Other terms are also used to distinguish psychiatric from non-psychiatric patients. Structural illnesses exist in the body; functional illnesses exist in the mind. Both words have bona fide meaning in the world of medicine. But more often than not, the word functional is slang that implies a patient’s symptoms are imaginary.

  Another slang term used to label patients, especially by non-psychiatrists, is supratentorial. Like a lot of slang, it is a bona fide word. The Merriam-Webster Dictionary defines it as “relating to, occurring in, affecting, or being in the tissues overlying the tentorium cerebelli.” So supratentorial refers to medical problems occurring in and around the brain tissue, such as strokes and brain tumours.

  Used as slang, supratentorial means the patients’ symptoms are all in their minds. A veteran ER physician who practises in western Canada told me she learned the word from an attending internist who was teaching her and some fellow students at the bedside of a patient who complained of dizziness. “The internist said right in front of the patient that her symptoms were supratentorial,” she recalls.

  My ER colleague says the internist used the term to denigrate the patient’s symptoms. “The internist was trying to tell us that the patient was not going to be a good teaching case,” she says. “The sense I got was that we were going to listen politely to her story and then move on to the next patient.”

  Even more telling is the fact that the whole psychiatric versus non-psychiatric split is an artificial construct. Psychiatric diseases—from schizophrenia to Tourette’s syndrome—have an organic basis. It’s seldom “either/or” but rather “both.”

  “You can scan the brains of people suffering from depression with functional MRIs that show change in various brain circuits,” says Quinn. “You can see clearly how it is, in fact, an organic pathology.”

  Still, many health-care workers think psychiatric patients don’t have real diseases. So what does that say about those who choose this branch of medicine?

  “I don’t feel like our field is as prestigious as primary care,” says Jason Lai, a psychiatric nurse who works at a mental health agency in Ohio. “I feel like primary care [family and internal medicine] probably thinks of us as not as scientific as them. And in some ways it’s true, because medicine understands the brain the least.”

  The fact that much of psychiatry isn’t rooted in science makes many doctors, including psychiatrists, uncomfortable, and contributes to the invention of slang.

  “Overall, what slang in both medicine and psychiatry reflects is our own discomfort as providers with aspects of what we do,” says Robert Klitzman. “Humour often covers awkwardness and discomfort.”

  He says the discomfort—which comes from uncertainty about the cause of psychiatric diseases, the effectiveness of treatments and the difficulty of studying the brain—gives rise to psychiatric slang.

  Like the young intern Roy Basch in his novel The House of God, Dr. Stephen Bergman left an internship in internal medicine to become a psychiatrist. “What psychiatrists do does not have that basic foundation in reality,” says Bergman. “In some few areas, like bipolar illness and in schizophrenia to some extent, you have some data on real interventions with drugs that work—very few, mind you. And very few when you take into account side effects, and even fewer when you find out that placebo works almost as well as every anti- depressant in mild depression.”

  The result is that the whole profession, including the patients it tries to help, becomes stigmatized. You can see the stigma in the slang used by doctors to refer to their psychiatric colleagues.

  As Peter Hukill and James Jackson catalogued in a 1961 article, it was common back then to refer to psychiatrists as head shrinkers, spooks and wig pickers. Such slang terms would almost never be used today because they would be regarded as overtly pejorative not just of psychiatrists but of their patients. However, a 2003 article in the journal Ethics & Behavior referred dryly to psychiatrists as members of the Freud Squad. I have certainly heard that one used recently.

  The fuzzy science behind psychiatry creates diagnostic ambiguity that provides fertile ground for slang. In addition, the absence of solid scientific data means that the disorders listed in the DSM are constantly being revised and augmented. Between the first and second editions of the manual, the list of diagnoses increased from 106 to 182, while the third edition named 265. By the time DSM-IV was published in 1994, the volume had ballooned to include more than 300 disorders.

  Many experts have criticized the growth of diagnoses listed in the DSM, often making the link between new illnesses and opportunities for pharmaceutical companies to make money. One such critic is Dr. Daniel Carlat, an American psychiatrist and author of Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations about a Profession in Crisis, published in 2010.

  “The DSM and pharmaceutical companies have long been engaged in a symbiotic dance, with each partner supporting the other,” Carlat wrote. “The proliferation of diagnostic labels has proved crucial for the growth of the pharmaceutical industry.” Carlat says that while he believes in the value of certain drugs, when drug companies advertise a new cure for a condition, this benefits the APA because psychiatrists will buy the latest edition in order to objectify the treatment of their patients.

  Bergman agrees. “In modern psychiatry, diagnosis is determined and written down in the DSM manuals,” he says. “Who publishes the DSM manuals? The American Psychiatric Association. How much money do they make from that? Millions. Most of their money to support everything they do comes from the DSM. Everybody has to read it.”

  DSM-V—the latest edition—was released in May 2013. Its publication was mired in controversy, with extended debates about the inclusion and exclusion of certain illnesses. In fact, much of people’s anger centred on the creation of categories many people wouldn’t label as illnesses at all. In DSM-IV, bereavement excluded a diagnosis of major depression. But in DSM-V, the bereavement exclusion was lifted, enabling doctors to diagnose with depression patients grieving the loss of a loved one. In effect, grief and the depression that goes with it went from being just part of life to being a psychiatric disorder.

  Resistance to the new order of things came from some unlikely sources. “Psychiatry is rapidly expanding and normal is shrinking,” wrote Dr. Allen Frances, chair of the DSM-IV task force and a professor emeritus at Duke University in Durham, North Carolina, in an article in that appeared March 30, 2013, in the Huffington Post. “We need to rein in psychiatry and rein in the drug companies. We should get back to treating the really ill who need us badly and let people with everyday problems solve them with their own resources and resiliency—and not with a potentially harmful pill.”

  Klitzman doesn’t think getting rid of the DSM is the answer.

  “I guess it’s tempting to see it as a necessary evil,” he says. “However, I think the late
st version could’ve been done better. I think they could’ve spent more time on making it better than they did, and field-testing it more.”

  * * *

  Given that the line between normal and psychiatrically ill patients is blurred, it’s no surprise that psychiatric labels seem more like slang than words that define something important.

  “It’s difficult because another aspect of psychiatry is that it describes phenomena that one sees in people in everyday life,” says Klitzman. “Take narcissism. People use the term narcissism [all the time]. It’s part of common parlance. But in DSM, narcissistic personality disorder has clear criteria.”

  The psychiatric terms found in the DSM are supposed to be used to make a diagnosis. All too often, doctors—even psychiatrists—use such terms as narcissist not to diagnose but to label a patient. And when that happens, the diagnostic term becomes yet another piece of medical slang. I call that the weaponization of psychiatric labels.

  Narcissism, called narcissistic personality disorder in the DSM, is a prime example. The word as it’s commonly understood comes from a Greek myth about a boy named Narcissus who fell in love with his own reflection.

  The DSM’s list of defining criteria for narcissistic personality disorder includes approval-seeking behaviour, a sense of entitlement and a predominant need for personal gain.

  “Narcissist is a term that’s thrown around a lot to devalue patients,” Quinn says.

  It turns out that the term can be used to devalue family members of patients as well. A resident says he remembers a male patient with an eating disorder who was having a lot of trouble accessing services. His medical condition made him ineligible for acceptance into a specialized treatment program. The young man attempted suicide, which led to him being admitted to hospital. The patient’s boyfriend was a lawyer and, as his profession requires, he was wearing a suit when he came to the hospital to speak to the psychiatric staff about his significant other. “Oh, he looks pretty narcissistic,” the resident remembers a member of the psychiatric team saying when he first saw the boyfriend.

  The lawyer was advocating strongly on behalf of his partner, spouting suggestions and saying at one point that he was willing to call an influential business associate “Would it help if I spoke to him?” asked the boyfriend “Maybe he could get him into one of these programs. Maybe they could change the criteria.”

  When the team left the room, the accusations of narcissism returned, now with more intensity. “Wow, this guy’s so narcissistic,” one team member said. “I can’t even handle this,” said another. The resident was taken aback by his colleagues. “The reality is that this man’s partner was in a lot of stress,” he says. “Having an eating disorder is a high-mortality thing. It’s not a joke. This patient was in a lot of trouble and the system was failing him. The lawyer was using every little thing he could find to try to help his partner, which I think anyone would ever want to do. But because he was advocating forcefully, they thought he had to be narcissistic.”

  I put the story to Dr. Robert Klitzman, the veteran psychiatrist. “I guess you can call that a kind of slang,” Klitzman concedes.

  The other diagnosis that often gets turned into a pejorative label is borderline personality disorder (BPD).

  A senior medical student told me about a patient with advanced diabetes. The patient was in and out of hospital frequently. Her medications were being juggled in an attempt to improve her condition, but nothing was working. Her anxiety seemed to increase relative to her body’s decline. She became very demanding.

  One day, during rounds, a colleague of the med student presented the patient’s history and current condition to the team. He had hardly finished his synopsis when the attending physician cut him off. “Oh,” he said, “sounds like a borderline.”

  The student says there was no evidence that the patient had a personality disorder. “She was legitimately very stressed out about the impending end of her life,” he says. The budding physician says the woman had gone through several doctors and many different treatments without feeling better, so she was appropriately distressed.

  When the attending physician called the patient a “borderline,” he didn’t mean it as an additional diagnosis so much as a piece of slang to describe a patient who is frustrating her doctors.

  Psychiatrists are generally more empathetic toward their patients than people like me are. But Quinn says even they will use the term borderline as a pejorative. Quinn was on his first rotation as a senior medical student when he heard a psychiatrist refer to a patient not by the formal term BPD but by borderline.

  One doctor who isn’t surprised that some psychiatrists use the term borderline as a piece of slang is Stephen Bergman.

  “It’s slang because the fact that such patients piss off even psychiatrists is the driving force to try and figure out how to deal with them,” says Bergman. “It’s pejorative because it’s pejorative in psychiatry to a large extent, too. When I was starting out, nobody wanted to deal with borderlines. They were too hard.”

  Still, psychiatrists are relatively unlikely to use borderline as slang. Other mental health professionals aren’t quite as reluctant. Sarah Reynolds, the psychiatric emergency nurse, says she has referred to teenagers as “baby borderlines.”

  “You can’t actually diagnose borderline until the person is 18 years of age,” says Reynolds. “We’ll say, ‘This looks like a borderline.’ It’s like they’re borderline-in-training. They’re beginning their borderline career and they could either go one way or the other.”

  The fact that baby borderline exists at all is ample evidence of an adverse prognosis that justifies the term. And it’s not the only term used to describe borderlines of a tender age.

  “There’s the teddy-bear sign,” says Reynolds. “If someone comes in with a teddy bear, that’s a borderline sign. And there’s the suitcase sign. We always see that as a bad sign—someone who comes with the intent to stay for many weeks.” Sometimes, the patient gets labelled with both slang terms. “People actually come in and sit the teddy bear down on top of the suitcase.”

  Some psychiatry residents at Dalhousie University in Halifax, Nova Scotia, told me they’ve heard baby borderline used there as well.

  Terms like these are cruel and dismissive of teenagers exhibiting the early signs of BPD. Perhaps they indicate doctors’ frustration and despair that a young patient is destined to be diagnosed eventually—and there’s little or nothing even trained professionals can do to stop the course of their mental illness.

  Still, Robert Klitzman believes there may be diagnostic value in using such slang: “Say an 18-year-old comes in clutching a teddy bear. There’s something a little off about that. It’s not specific diagnostically, but there may be symptoms and signs that have great sensitivity and specificity and others that are looser or suggestive or form a constellation.”

  Steven Bergman says the use of borderline as a label is due in part to the way BPD was formulated in the DSM. “The reason they’re called borderlines is because it was a garbage category,” Bergman explains. When he began his training in the 1970s, only two categories of psychiatric illness existed—psychosis (in Bergman’s words, “really crazy people,”) and neurosis (“people who were miserable but in touch with reality”). Everyone else was labelled borderline, because they bridged the border between the two.

  Borderline personality disorder first appeared in DSM-III, published in 1987. “The fact that it is on the border of clearer definitional categories is a problem because it’s being defined by what it’s not rather than what it is,” Klitzman says. “That’s always going to be a problem because it suggests from the get-go that there’s going be a lack of clarity about it.”

  Even a psychiatrist as seasoned as Klitzman says it’s difficult to know when borderline is a diagnosis and when it’s medical argot.

  “It’s not that precise,” he says. “
Given that some of the phenomena that led one to call someone a jerk or an asshole or a bitch are characteristics that one may also see in someone who [has] a borderline personality disorder, it’s tempting to apply borderline personality more broadly. So, for instance, people are being described as being ‘borderliney.’ It’s taking the verbal tools of psychiatry and using them to make sense of the behaviour, but also to put down people.”

  If a psychiatrist as esteemed as Klitzman sees the connection—not to mention the justification—for borderline as a slang term, there must be something to it.

  * * *

  During my interviews for the book, health professionals in just about every specialty named borderline patients as among the most annoying. They are also labelled by slang terms such as splitter, and are said to belong to cluster B or axis deuce (or axis two).

  When a colleague tells me the patient I’m about to see is a borderline, what she’s actually saying is, “Brace yourself. This patient is going to drive you up the wall.”

  Psychiatric nurse Sarah Reynolds says that “in the ER, people can get diagnosed as borderline after five seconds.” Once, she overheard a doctor saying to his resident, “You can always tell when someone is borderline because they drive you crazy.”

  Emergency physicians routinely teach their residents that any time a patient provokes anger in the physician, the patient is probably a borderline. I’ve met colleagues who boast that they can diagnose a borderline on the spot. To me, that’s dangerous to both the patient and the physician.

  Las Vegas hospitalist Dr. Zubin Damania is one of the most caring physicians you will ever meet. Still, even he finds borderlines difficult to deal with. “These patients are some of the hardest to take care of,” he says. “To half the staff they are super sweet and nice and pleasant, and to the other half they are absolutely nasty and vicious and evil, and often times those halves will switch within a day.”