Diagnosing Britney Spears

In the days since troubled pop star Britney Spears was briefly hospitalized, speculation over her mental state has exploded. Pundits have publicly probed her health. One TV host, Dr. Drew Pinsky, whose show about celebrity rehab is debuting this week on VH1, took a grave view, opining on CNN's "Larry King Live," "I have been saying for many months that her life is in grave, grave danger, and the recent hospitalization is really just symptoms of exactly that."

The grand master of TV psychology, Dr. Phil McGraw, even planned to dedicate an entire show to Spears's health, but at least he had met with her in the hospital on Saturday at the request of her family. But Dr. Phil quickly reversed course, releasing a statement on his Web site saying that he had canceled the episode "out of consideration for the family" and because he said Britney's situation was "too intense."

However, Dr. Phil did make at least one point worth repeating before he bowed out: "Clearly, it is not just Britney's family struggling to find a way to protect adult children who cannot be ordered or compelled to seek help." NEWSWEEK's Jenny Hontz spoke with Dr. Andrew Leuchter, a professor of psychiatry and biobehavioral sciences at the UCLA School of Medicine, about the Spears case and the less titillating issue of ordinary families who struggle with adult mental illness. Excerpts:

NEWSWEEK: Celebrity doctors and therapists have been speculating about Spears's mental state without having examined her. Isn't this problematic?
Dr. Andrew Leuchter: If one speculates about the presence of a mental disorder in the absence of a direct examination, number one, the chances of making errors in judgment are pretty high. And number two, it's really nothing I think most clinicians would be comfortable doing … Psychiatry, at the end of the day, is very much like the rest of medicine. Everything is based upon a careful examination. One would never presume to be able to make a medical diagnosis by looking at somebody on TV. And one should never presume to make a psychiatric diagnosis by looking at someone on TV, either.

Some of these commentators have suggested that Spears may have bipolar disorder. What exactly is it and what are the symptoms?
Bipolar disorder is a disorder where people not only have episodes of depression but also have episodes of mania or hypomania. Those are periods of elevated mood, where people report having increased energy, commonly a decreased need for sleep. Sometimes they can be quite agitated, and in more severe cases of mania one can even have psychotic symptoms—one does not necessarily know what is real and what is not. And people with bipolar disorder sometimes cycle between depression and episodes of mania or hypomania. And some people with bipolar have primarily depression with very rare episodes of mania.

What are the risks of bipolar disorder?
With any mood disorder, such as depression and bipolar disorder, the most common problem is that somebody doesn't function very well. When your mood is very, very down or very up, it's hard to get through day-to-day life. They would show poor judgment and sometimes might be harmful to themselves … There are higher rates of use of alcohol and drug abuse in general among people who have or depression or bipolar disorder.

Are they trying to self-medicate?
That's one of the theories, yes. If somebody has a mood that is very unpleasant for them, they not uncommonly try to do something to relieve that mood. It might be use of a stimulant or alcohol. This does not apply to most people with a mood disorder, but people with bipolar disorder or major depression are more likely to use some kind of substance, either to try to get them over their mood problem or, again, because they are more impulsive and might be showing poor judgment.

If someone has a problem with substance abuse and addiction, could his or her behavior be mistaken for a mood disorder?
That's why we want to examine somebody before coming to a conclusion about what's driving what. It is possible for somebody to appear to be severely depressed or manic, and it could be primarily a result of [this person] having a substance abuse problem. So in the absence of taking a careful history, and sometimes having what we call collateral sources—friends or family members who can tell us what else is going on in somebody's life—it's really hard to come to any conclusion about the source of somebody's problems.

If somebody has a family member, an adult child or a spouse who is exhibiting behavior indicative of a mental disorder or substance abuse, what can family members do if that person is reluctant to get help?
That is one of the most vexing kinds of problems for families. I get calls about this all the time. I got one over the weekend from a family going through this. In our society, because we do have very strong protections for individual civil rights, it can be very difficult to compel somebody to get help they need. If one is an adult suffering from major mental illness, [and] if one doesn't want to get help, it's possible to avoid getting that help. And it can be very difficult to push somebody to get help until they get to the point where they can't care for themselves. So, in California for example, unless one is a danger to oneself, a danger to others or gravely disabled, one cannot be compelled to receive any kind of treatment. Even then, one may have to go to court in order to get the court to order specific types of treatment.

If a patient such as Spears is brought in involuntarily but is released within the 72-hour window allowed under California's 5150 code, does that mean she does not have a mental disorder?
When somebody is confined involuntarily, one is supposed to be reassessing them on a regular basis. If at any time it's the judgment of the treating physician that the person is no longer a danger to self, a danger to others or gravely disabled—whatever it is that brought them in—then they should be released. Sometimes we can find that people exhibit bizarre behavior or are a danger to themselves because they are intoxicated or high on something. And once that situation is cleared, we find they no longer meet the criteria to be held.

But if somebody is released in the middle of a 72-hour hold, that does not necessarily mean they don't have a mental disorder?
Correct. The great majority of people, more than 99 percent of people, with some kind of psychiatric diagnosis, would never be held against their will. Psychiatric disorders are extremely common, and with most psychiatric disorders people are able to function day to day. Most people with depression and bipolar disorder lead normal lives [usually with treatment, which usually includes a combination of psychotherapy and medication].

What is the best thing for a family to do if a relative is exhibiting bizarre behavior but is not in a situation that might require hospitalization?
The most effective intervention is to encourage [them] to get help. Clear, consistent feedback on, "You know, I think you have a problem. I think you need help." Getting other family members to step up and give the same clear message, looking for the opportunity. Sometimes the only time to convince somebody to get help is when they are in crisis.

I would imagine that losing visitation rights to your kids, as Spears did, would be a pretty strong motivator.
I don't want to comment on Britney Spears in particular, but I will tell you, what's going to motivate any one individual is going to depend a lot on a few factors. Number one, what is important to that individual? For some people, losing a driver's license is a major motivator to get into treatment. For other people losing a spouse or a job can be the major motivator. Sometimes it takes the threat of legal action to get somebody into treatment. There's always the very important factor of how much insight somebody has into their situation. Because it can take a number of life calamities for some people to realize they've got a problem.

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