Monday, March 30, 2009

The Game Changes

March 29, 2009 may go down as a watershed day in the history of psychological disorders. The Detroit Tigers Baseball Club placed one of their players, Dontrelle Willis on the disabled list. Making the disabled list of a professional baseball team is of no particular concern to those who follow mental health issues, but the circumstances in this particular case may be profound in their implications.

Mr. Willis made the disabled list not because of an injury in the manner which is most common to baseball players and professional athletes, Mr. Willis was told that "blood tests" had confirmed to doctors who were treating Mr. Willis that there was cause for concern. What makes this such a watershed day are several circumstances surrounding the case have created a kind of perfect storm that threatens to cause seismic tremors in both the sports and psychiatric communities.

Not the least of these concerns is the pairing of the words "blood test" and "anxiety disorder" in reports surrounding the placement of Mr. Willis on the disabled list. As those who follow the mental health medical world know, mental diseases are classified by the Diagnostic and Statistical Manual that governs such things known specifically as DSM-IV-TR. Like all mental disorders, anxiety is labelled and diagnosed not by blood tests, but by laundry lists of diagnostic criteria. DSM-IV-TR lists thirteen categories of disorders, none of which contains the description "unable to throw a curve ball for strikes" within its criteria.

There are two mentions of blood tests for anxiety that I have located in research material, neither of which I can determine has commercial availability. Clearly, neither of the tests has been generally accepted as a diagnostic tool. Reporter Lynn Henning of the Detroit News who covers the Tigers has written about the delicate and mysterious nature of the placement on the disabled list, confirming that the baseball commissioner's office was consulted in the process. All of this is especially tricky when dealing with laws relating to confidentiality of personal medical records.

What provides additional intrigue to the situation is the amount of money paid to people like Mr. Willis to perform their jobs. Reportedly, the Detroit Tigers are contractually obligated to pay Mr. Willis more than 20 million dollars over the two remaining years on his contract. This makes the baseball club extremely interested in Mr. Willis's ability to perform his job. It also creates a very sensitive situation as respects insurance that clubs purchase to guarantee the ability of their athletes to perform the skills that they have been contracted to perform.

All of these issues have come together to create a kind of perfect situation to shine a light on the issues involved. Sadly, that light is also shone on Mr. Willis, who now, because of the loss of his ability to perform his job is subjected to the most cruel scrutiny by fans and interested parties.

The ramifications have already started to appear in other blogs. In particular, one blog has questioned the validity of the diagnosis and expressed anger in the following way: "I don't appreciate having my disease exploited to bail you out of your own stupid mistakes." The argument is that there were no reports of outward symptoms of anxiety, therefore how dare someone give a diagnosis of anxiety. This may be most unkind toward Mr. Willis in that views about such issues without first hand knowledge only perpetuates stigma and hostility toward what is by most accounts a rather tragic situation.

Most of us who have dealt with a mental illness in our close family do know the degree to which symptoms can be hidden from view and realize the tremendous loss of performance that can result from seemingly mysterious circumstances. In defense of Mr. Willis, he is at an age where his physical abilities should be at his peak. Like most people who seek to perform athletically at a very high level, it runs completely contrary to his history to suggest that he would want to do anything but perform at a high level. If one were to compare the type of scrutiny that he will undergo now as opposed to the attention he would get were he able to perform, there would be no question what any rational person would choose. One might conclude then, that the situation that Mr. Willis finds himself was not done by matter of choice. If it was by matter of choice, then one would conclude that some pathology was guiding that choice.

On a more basic level, the mystery surrounding sports performance and mental issues is littered with the wreckage of multiple careers, but it pales with the suffering of millions of people who suffer the same fate in their everyday lives. The situation that has now grabbed attention shows how poorly we deal with issues like the definition of illnesses like anxiety and how little we actually know about the loss of function in people of all professions.

If there is a silver lining to the story, perhaps it will come in the form of promoting understanding about the underlying physical causes of mental diseases and how to more accurately diagnose and treat them. The great weakness of elaborate classification schemes like DSM-IV-TR is that they simply describe collections of symptoms. They are not explanations of why there is a problem, they are simply a way to agree upon what a collection of symptoms should be called. As such, their weakness is apparent. Should Mr. Willis suddenly begin to throw pitches that are in the strike zone and start getting batters out instead of watching the pitches be hit out of the stadium for home runs would he no longer suffer from anxiety? Clearly, something has caused him to not perform at an expected level. Is it a disease that is rooted at a chemical level? DSM-IV-TR cannot tell you nor can medical science at this point in time. What is more important is if we can discover the real cause of his inability to do what he was able to do before and help him regain his skill, think of what might be done for the millions of others among us who have lost their ability to perform at more modest levels.

The discussion needs to engaged about how outward symptoms and behaviors are related to brain and physical function. Were there tests that could identify particular pathologies of function and lead to treatments for those like Mr. Willis that suddenly lose the ability to perform a function that they once did with relative ease, many would benefit. Until that knowledge is developed, we will all suffer while watching promising careers and lives languish in frustration. Those who find themselves in a similar situation deserve better. If the stakes are high enough, perhaps this event will spark interest in what can be done to help those who suffer the same fate. It could be a defining moment in looking for causes, not stigmatizing those who suffer from similar circumstances.

Let's hope that the search for causes prevails. The fact that physical tests are being discussed give a glimmer of hope that understanding might follow. Goodness know that simply placing blame and stigma is not the answer.

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