As psychiatrists have gone from doing both psychotherapy and prescribing psychiatric drugs to doing basically nothing but writing prescriptions, many of them have fallen into some very bad habits. When all you have is a hammer, everything starts to look like a nail. In this case, when all you have are drugs, everything starts to look like a brain disease.
Personality problems, anxiety, agitation, and reactions to problematic family and other interpersonal interactions have been widely mis-labeled as biological/genetic brain diseases. Quite a change from when real brain diseases like autism and schizophrenia were thought to be behavioral disorders!
One of the worst trends in this regard is the use by psychiatrists of “symptom checklists” to save time in making a psychiatric diagnosis on their patients. Frankly, the doctor’s secretary could make a diagnosis just as easily as the doctor could using this shortcut. Patients are quizzed about specific symptoms without even seeing if they understand what the symptom must be like in order to be clinically significant.
The evaluation of psychiatric symptoms must take into account their psychosocial context, their pervasiveness, and their time course in order to distinguish them from everyday mood reactivity due to life experiences. Additionally, some symptoms are seen in a wide variety of different psychiatric conditions, and an understanding of these three factors, as well as the taking into account of the presence of other symptoms necessary in order to qualify for a given diagnosis, is essential in differentiating the different disorders.
For example, symptoms seen in a variety of psychiatric disorders as well as in normal people under stress include:
• Impulsivity
• Irritability
• Aggression
• Hostility and Rage
• Moodiness and sudden mood changes
• Agitation
• Poor Concentration
• Disorganization
Irritability can be seen in anxiety, major depressive disorder, dysthymia, mania, personality disorders, and in someone who’s just having a bad day.
Nowhere is this problem more problematic than in the differentiation between a major mood disorder called bipolar disorder (which used to be more accurately called manic-depression), and a personality disorder spawned by dysfunctional families called borderline personality disorder (BPD). Psychiatric drugs only help with anxiety and reactivity in the latter disorder – psychotherapy is by far its most important treatment. True bipolar disorder, on the other hand, does not really respond to psychotherapy at all, but is treatable and preventable with certain medications.
In my 35 years experience of taking complete psychiatric histories, and in my 18 years of experience watching psychiatric residents (trainees) taking psychiatric histories, I know that asking patients about prior episodes of mania is one of the more difficult things to do in psychiatry. Almost everybody has been euphoric, partied all night, and felt on top of the world at one time or another. Patients almost invariably answer yes if asked about theses symptoms. The patient has to be made to understand that in mania, these symptoms are really extreme, have to last several days, be relatively unresponsive to anything that is going on in the environment, and be completely different from the patient’s normal functioning. It literally has to be a Jeckyl and Hyde situation.
You also have to rule out other potential factors that may account for a patient’s “yes” answer. For example, it may seem absurd when you think about it, but many psychiatrists stop after asking a patient about whether they have ever had a period in which they stayed up all night for several days while remaining energetic. They don’t ask obvious follow-up questions like, “Did you nap in the daytime?” “Were you using methamphetamines or cocaine at that time?” or even, “How much coffee were you drinking then?”
Furthermore, despite objections from the people who wrote the diagnostic manual in psychiatry, some psychiatrists believe that a “manic” period can last just an hour or two, or even a few minutes. They say that folks who have brief mood swings or go into a rage are “rapid cyclers” or have “sub-threshold bipolar disorder.” There is absolutely not one bit of credible scientific evidence that short-duration “mood swings” are in any way related to bipolar disorder. The docs pushing this idea literally made this up in order to justify selling and prescribing more drugs. They pulled it out of their you-know-whats.
Ironically, a patient who is actively manic and one who is acting out from borderline personality disorder look nothing alike if seen when symptoms are present. The difference is not subtle at all! Furthermore, if psychiatrists know the tricks of the trade (and most do not), they can get a patient with BPD to turn off and on most of their symptoms like a faucet. Manic patients stay manic no matter what the doctor does in the short term short of knocking them out with sedatives.
Nonetheless, the purveyors of bipolar disorder (my ass), tout a screening symptom checklist called the Mood Disorder Questionnaire (MDQ). They claim it is almost as accurate as a full psychiatric interview in diagnosing bipolar disorder. Sure it is – a really, really BAD psychiatric interview. Actually, patients who score positively are just as likely to have borderline personality disorder as bipolar disorder, according to a study published online March 23 in the Journal of Clinical Psychiatry by Mark Zimmerman and colleagues. They found that of the 98 patients who screened positive on the MDQ, 23.5% were ultimately diagnosed as having bipolar disorder and 27.6% as having borderline personality disorder.
My colleague in the Association for Research in Personality Disorders, Joel Paris, MD, of McGill University in Montreal agreed with Dr. Zimmerman et.al, saying that the MDQ scale is "completely invalid." As he told Medscape Psychiatry, "The scale lists all the symptoms of bipolar disorder, but it does not attach any time scale."
Another study in the Journal of Clinical Psychiatry by the same group (Reggero, Zimmerman et. Al. V,71:1, January 2010, pp.26-31) showed that 40% of patients in their sample who met clear DSM criteria for borderline personality and not for bipolar had been misdiagnosed as bipolar by a prior mental health professional, as well as 10% of all of the other patients.
These patients are getting potentially toxic medications while not receiving the psychotherapy they need. IMHO, this situation borders on criminality.
Wednesday, April 7, 2010
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To tweak your paragraph around which I have inserted quotes,what is schizophrenia if not "personality problems, anxiety, agitation, and reactions to problematic family and other interpersonal interactions have been widely mis-labeled as biological/genetic brain diseases." In my 26 years experience as a mother of someone once labelled as schizophrenic, I'm willing to go down the route of family problems. This is where psychiatry is shirking its responsibilities of offering real insight to struggling patients and families in favor of labelling it a brain disorder/disease.What is it? A disorder, a disease or a problem? The real work of psychiatry should be to deal with it as a problem of living, rather than whipping out the prescription pad and abandoning the notion of psychotherapy, because, hey, everybody knows schizophrenia is a brain disorder.
ReplyDeleteMy particular beef with most psychiatry is that schizophrenia is always held out as a "special case" when, in fact, it is a reaction to problematic family and other interpersonal interactions, just like BPD and the other labels. You refer to schizophrenia as a brain disorder/disase. Schizophrenia has been termed a "thought disorder" as a way to try to distinguish it from a "mood disorder". Pharma persists in calling it a brain disorder so it can sell dubious drugs for it.
Ms. Forbes - you certainly have surprised me. I was expecting to be skewered for "blaming" certain psychiatric disorders on disturbed family interactions instead of agreeing that they are brain diseases, not the other way around! How refreshing that you view the family interaction explanation as the more hopeful one.
ReplyDeleteI have not examined your son, obviously, so I am not in a position to comment about the correctness of his diagnosis. I already stated my position on schizophrenia in an earlier post.
Thanks for your comment.
"The evaluation of psychiatric symptoms..."
ReplyDelete1) Psychiatric evaluation can not be done under duress, but they are done every day when the patient does not have the freedom to leave.
The anger and resentment at being held agaist their will, will alter the interaction.
2) Psychiatric evaluation can not be done to people under the influence of drugs. Legal psychiatric drugs or illegal ones.
3) Psychiatric evaluation can not be done to people who have not slept, and not ate.
4) Psychiatric evaluation can not be done to people in withdrawal, a chemical dependency.
Mark: in response to your comments:
ReplyDelete1) "Psychiatric evaluation can not be done under duress, but they are done every day when the patient does not have the freedom to leave.
The anger and resentment at being held agaist their will, will alter the interaction." I absolutely agree with you, and a good psych eval must take this fact into consideration.
However, it's relatively easy to tell when a patient is flagrantly psychotic, and the examiner can also get info from other sources such as the police, family members,etc.
Although commitment laws have a long history of dispicable abuses, sometimes they are necessary - unless you'd rather the patient end up dead (though at least you could say that they died with their civil rights intact), sleeping on the street in a cardboard box and pissing on your or your neighbor's doorstep, or in jail.
Since the state hospitals were emptied, there are far more severely mentally ill idividuals being treated in jails than in hospitals.
2) "Psychiatric evaluation can not be done to people under the influence of drugs, Legal psychiatric drugs or illegal ones." That depends on the drug, the dose, and the patient's tolerance. The effects of the drug should also be taken into account by a good psychiatrist.
3) "Psychiatric evaluation can not be done to people who have not slept, and not ate." - I totally agree with you.
4) Psychiatric evaluation can not be done to people in withdrawal, a chemical dependency. Again, I agree with you completely. The doc needs to wait until they are no longer in withdrawal to make a good eval, or until they are no longer intoxicated and back to their baseline state.
To Dr David M. Allen
ReplyDeleteThank you for responding , agreeing with most and continuing the discussion.
I do have to question with "However, it's relatively easy to tell when a patient is flagrantly psychotic, and the examiner can also get info from other sources such as the police, family members,etc. "
The "family" will definitely give information from THEIR point of view.
In court know as "hearsay evidence".
The "patient" is usually in conflict with the family or they would not be a "patient".
From this other website Ron: "Yes. Everyone is trying to brainwash me. My wife, my parents, the sales manager. Everyone is trying to push their thinking into my head."
Mark:
ReplyDeleteAmen, brother. Right again. What families can do was illustrated dramatically extremely well in the movie "Francis" (the theatrical one with Jessica Lange, not the TV movie version). This sort of thing happens all the time, although in my experience it happens clinically much less frequently with the families of psychotic patients than it does with patients with, say, "anger control problems" or "ADHD."
A good psychiatrist takes all information with somewhat of a grain of salt, and judges its reliability, the source's potential motives for distorting it, etc.
In the example from the other website that you posted, it was clear that this patient was saying metaphorically that his family was trying to mold his behavior to their liking, and that he was not at all psychotic.
A patient with with schizophrenia, on the other hand, believes, and will tell you, that others are literally putting thoughts into his head with telepathy, osmosis, or some bizarre device. The psychiatrist in the example was an idiot.
In Memphis, the police have a "Crisis Intervention Team" that is well-trained in psychiatry and domestic violence, and is a model for other police departments nationwide(I used to be involved in their training). Information from them is in general pretty reliable.
If they told me that the patient was found running nude on the freeway shouting out that the FBI and the CIA were tracking him with ray guns because he knew about the Illuminati, I found I could in most cases believe it, even if the patient said he was just minding his own business when he got picked up by the cops. The cops had no motive for making that stuff up. They had no dog in the hunt, as they say in the South.
Thankfully in psychiatry, unlike in court, we don't have to prove anything beyond a reasonable doubt, so hearsay is admissable.
The problem takes place when a psychiatrist ignores some very reasonable doubts, especially if they had spent very little time evaluating the patient or had used a symptom checklist. Unfortunately, this is happening more and more all the time.
re"A patient with with schizophrenia, on the other hand, believes, and will tell you, that others are literally putting thoughts into his head with telepathy."
ReplyDeleteIn a sense telepathy exists, if the person has empathy or love for his complaining family members. He/she can see the situation from their family's perspective and his/her own perspective at the same time. He/she may feel bad/guilty for disagreeing with the loved ones, but at the same time still has his/her own feelings-thoughts of self interest.
In a game of chess the oppositions moves must be empathized with and understood to know their possible future moves.
How else do you describe an internal conflict?
Its just a confusion of empathy (with conflicts) as telepathy.