The Shadow Syndromes - by John Ratey
"Quirks and Oddities May Be Mild Forms of
A Review by JANE BRODY
They may sound like nothing more than personality quirks --
a working mother who is competent and controlled at her job but explodes at home when
small things go wrong or a computer programmer who is the ultimate loner, sitting hunched
over his terminal night and day.
One woman could never see long projects through to their end. Instead of setting reasonable goals and meeting them, she would jump into a project with both feet only to find her initial energy and enthusiasm fading before she completed it when a new project captured her attention.
One man was obsessively concerned about his body, always scanning it for signs of trouble. When something does happen, he cannot stop thinking about what it may mean. As a child, he was obsessive about sports activities: "I wouldn't just pitch one hour a day; I would stand in front of a wall and make 5,000 pitches, from 11 a.m. to 4 p.m."
But, in fact, each of these people was eventually found to be suffering from what Dr. John J. Ratey, a psychiatrist, has named "shadow syndrome," a mild form of a well-recognized neuropsychiatric disorder like depression, attention-deficit disorder, obsessive-compulsive disorder, mania or autism.
Ratey, who is executive director of research at Medfield State Hospital in Massachusetts and is affiliated with Harvard Medical School, said a person with shadow syndrome might have three or four symptoms of a recognized disorder that was usually defined by 10 or so symptoms. That person may have serious difficulties meeting life's challenges but never know why. More often than not, his clinical experience has shown, such people blame themselves for their social, academic and professional failures.
Millions of these people are "falling between the cracks," said Dr. Michael Liebowitz, a psychiatrist at the New York State Psychiatric Institute at the Columbia College of Physicians and Surgeons. "Yet their symptoms warrant fixing. They can be very distressing, even disabling."
Dr. Robert Spitzer, chief of biometric research at the institute, said: "Mental disorders exist on a continuum, like blood pressure and cholesterol levels. It is somewhat arbitrary as to where we make a cutoff between health and disease. Throughout the history of medicine, first the most severe forms of a disorder have been recognized, then the milder forms."
But Dr. Harold Alan Pincus, director of research for the American Psychiatric Association, said he was concerned about "the rush to get out brand names" for so-called subthreshold disorders before they have been systematically evaluated. "We must first study the natural history of the conditions, then study treatments to see if they will alter that history," he said.
But he added that even if the symptoms of a person's condition did not exactly fit established diagnostic criteria, "it can be classified as a mental disorder if it is associated with clinically significant distress or dysfunction."
And even problems that do not seem severe can have serious consequences. Dr. Frederick Goodwin, former director of the National Institute of Mental Health and now a professor of psychiatry at George Washington University School of Medicine, said, "Many of these milder states are chronic and can be even more disruptive of a person's life and ability to function than a well-defined clinical syndrome that comes and goes, say, every three to six months and lasts two weeks."
Subthreshold syndromes can, for example, result in poor school performance, an inability to hold jobs, difficulty making and sustaining friendships, marital discord, inappropriate behavior as a parent and a general failure to fit into society. Yet, all such syndromes respond well to treatment, Ratey maintains in a new book, "Shadow Syndromes," written with Dr. Catherine Johnson, published this month by Pantheon ($25.95). In fact, he said, "for most people with shadow syndromes, just understanding the origins of the behavior is the biggest help."
Most surprising, perhaps, are the people who turn out to have a subclinical form of autism, a neurological condition usually present at or shortly after birth in which individuals are drawn into their own world and fail to make contact or communicate with others. Dr. Edward Ritvo, a professor emeritus of psychiatry at UCLA, and his co-workers uncovered fascinating cases of mild autism among the parents of all 380 autistic children identified in Utah.
Although they had married and had children and were generally of normal or above-average intelligence and often very successful, these parents were always deemed to be "weird," "odd ducks" or "nerdy." Unlike true autistic people, they had no language problems, but they had difficulty "grasping the subtleties of interpersonal relationships and didn't understand the social inappropriateness of their behaviors," Dr. Ritvo said.
"They lived very specific, concrete lives, learned what they had to do and did it," he said, but could become totally unnerved and confused by any change in their routines. Ratey said children with mild autism were often too uncoordinated to do sports and too poor at grasping social cues to have friends. "These people suffer from a congenital lack of grace, they don't know how to do the interpersonal dance," Ratey remarked. "Their intentions are good, but people think they are awful, arrogant, self-important because they come across so boldly when they do say something and because they tend to say things that are completely inappropriate, that rend the seemliness of life."
The treatment for different subthreshold syndromes may involve medication, traditional talk therapy, cognitive or behavioral therapy, support groups or simply coaching -- teaching people step by step how to act in various situations, said Johnson, a writer and trustee of the National Alliance for Autism Research who lives in Los Angeles.
For those with a mild form of autism, a developmental disorder that in full-blown form results in a failure to communicate with others, Dr. Ratey said the first step was to stop blaming themselves for their difficulty making friends.
In treatment, Ratey said, they are taught how to conduct relationships: how to relate to people, how to recognize and respond to the anguish and joy of others, how to give and take, when to talk and when to stop talking. He added that the earlier in life a person with mild autism learned these lessons, the fewer the emotional scars and the better the
Those with mild attention-deficit disorder may also have serious social difficulties. Ratey described them as "impulsive, saying things too quickly, hurting people's feelings, then saying I'm sorry. "They may stand too close, be jerky in their movements and get too excited when someone says hello to them," Ratey said. "Kids don't like them
and they don't know why."
Like people with full-blown attention-deficit disorder, those with the mild form tend to be easily distracted and have trouble finishing things. Dr. Ratey said: "I know brilliant people who did all the hard research but never finished their reports. They might have won a Nobel Prize had they been able to finish instead of being attracted by the next problem.
"They have to learn how to compensate for the characteristics that can cause trouble in life. They need to develop techniques for maintaining order, reminders to keep them from forgetting what they are supposed to be doing from one minute to the next."
But even as psychotherapists are coming to appreciate the broad extent and potentially serious consequences of mild syndromes, managed health care increasingly threatens to discount them, Dr. Goodwin said. A person who does not meet the full criteria for a disorder may not qualify for treatment under managed care, he said.
Further complicating the treatment issue are concerns about labeling people with a psychiatric problem that could compromise their financial or occupational status and fears of "overmedicalizing" society in a way that may threaten individuality. Some critics maintain, for example, that widespread use of antidepressant medications like Prozac will wipe out idiosyncratic personalities that make life interesting. Dr. Johnson said,
however, that there is no evidence that any form of psychiatric treatment can "create a society of mental clones."
But, she added, there is ample evidence of suffering that can result from the various subthreshold syndromes. Especially common are people afflicted with mild depression, the people with short fuses, those who are joyless or overly critical, those who chronically see the glass as half empty. Rarely do they seek treatment, thinking instead that everyone feels the way they do, that they are merely stressed or burned out or that they have good reason for feeling negative. Goodwin said many such people were greatly helped by cognitive and behavioral therapies that taught them to focus on the here and now. "These therapies enhance scar formation," he explained. "Patients learn to look at
how issues affect them today instead of letting the past dominate the present."
For others with mild depression, a medication like Prozac may be a ticket to recovery, giving them the emotional energy to learn new, more positive ways of viewing the world and responding to situations. Mild forms of psychiatric disorders can also cause or aggravate physical health problems. A study of more than 9,000 Americans directed by Dr. Lewis L. Judd, a psychiatric researcher at the University of California at San Diego, revealed that those found to have subsyndromal depression were far more likely than the general population to experience insomnia, to feel tired all the time, to have
trouble concentrating, to gain weight and to think frequently of death.
And in a 1994 study by the Rand Corp., a research organization in Santa Monica, Calif., among nearly 4,000 patients receiving care outside of hospitals, those with mild depression were as likely as those who were severely depressed to have accompanying physical disorders as well as other psychiatric problems. Yet, primary-care doctors treating the patients' physical problems rarely recognized subthreshold depression as influencing their physical health.
Dr. John M. Zajecka, a psychiatrist at Rush-Presbyterian-St. Luke's Medical Center in Chicago, said it was common for people to have mild forms of both depression and anxiety that were "masked by other physical symptoms like headaches, musculoskeletal pain and backaches." He added, "Once their depression and anxiety are identified and treated, their physical symptoms improve as well.Primary care physicians should be hypervigilant in looking for psychological aspects of physical symptoms."
Dr. Alexander Glassman of the New York State Psychiatric Institute said that in addition to more medical illnesses, people withsubsyndromal depression were less likely to achieve their potential in school or the workplace and were more likely to start smoking and less likely to stop. Those suffering from subthreshold syndromes are sometimes slow to recognize these problems and fail to seek treatment. Zajecka said: "If their symptoms are not bad enough to interfere with all areas of functioning, they may hesitate to get treatment. They may minimize orrationalize their symptoms or write them off as due to life circumstances." Yet, the Chicago psychiatrist said, once treated, a common reaction of patients was, "Thank you for giving me my life back."
Copyright 1997 The New York
This is a review of the book when if first came out, February 4, 1997; NY Times Science Page; reprinted on NLDline with permission of the author.