Tuesday, August 3, 2010

Don't Ask, Don't Tell

I had the following exchange with another psychiatrist in the midst of a discussion on a Medscape blog about the frequent misdiagnosis of bipolar disorder:

Me:  I am saying that someone may appear bipolar when in fact he or she is really just acting out in response to family chaos or other environmental disturbances.  Mis-diagnosis stems from a failure of the practitioner to evaluate what is going on at home and under what circumstances the patient acts up, and to consider alternate possible explanations.

Family members will not usually volunteer the whole truth during a superficial visit with a doctor. Anyone who thinks that family members act the same way at home as they do in front of an authority figure, or that they will be totally honest about things like family violence or abuse, needs to get out more.

Psychiatrist #1:  This broad statement essentially implies and equates pediatric mental disorders with the family abuse and neglect. Misconceptualization of pediatric pathology is characteristic of orthodox thinking that always looks for proximal cause. The reasoning goes along the line "if child has problems, someone in the family caused them". And if the family does not offer any evidence of maltreatment,they are lying. A fundamental fallacy, in my opinion, that for decades prevented psychiatrists from understanding the nature of mental disorders.

Family, as the cause of psychiatric illness is a dangerous fantasy. Suspecting family members of hiding "the whole truth" is a regrettable statement from a professional.

Wow.  I never said I was equating pediatric mental disorders with family abuse and neglect, or that I assumed that if a child has a problem, someone in the family caused it.  I just said the family situation needs to be evaluated just like everything else.  It sounds to me like it is the writer who is saying that poor discipline or even child abuse is never an issue at all!  Family a cause of psychiatric illness?  How about behavior problems being mistaken for psychiatric illness?

Suspecting a family of hiding the whole truth in a superficial interview a regrettable statement?  Obviously this psychiatrist has never done any serious psychotherapy, or he would know that a patient may not reveal absolutely essential information about their situation until they have been seeing a therapist for months.  I once had a patient who did not reveal until one year into therapy that her father had been a junkie during her entire adolescense.

Let me see.  The other psychiatrist must think that his patients are all experts on psychiatric symptomatology so they can just volunteer all the important clinical information necessary for the doctor to make an informed clinical judgment.  They are so well read in psychiatry that they just know all the relevant factors a doctor needs to know about their home situation right off the top of their heads, even if they are not asked about something specifically. 

Of course, no one ever withholds information because they are ashamed of something, or guilty about something, or because they are not sure they can trust a complete stranger with their deepest darkest secrets and the skeletons in their family closet.  And all parents are completely aware that their trouble setting limits and saying no is feeding into their children's temper tantrums.  And we all know that people who are guilty of child abuse just love to tell everyone they know about it, especially someone who is legally obligated to turn them in to child protective services!  Why, everyone is just chomping at the bit to have their children taken away from them.

Oh, and one study showed that only 10% of the parents of children who are given complementary or alternative medicines tell their pediatricians about them.  The whole truth in a superficial interview?  I think not.

I know it is just a television show, but ever watch Supernanny?  When a family calls for her to come help them with a family problem, is she ever surprised by what she finds when she actually watches them in action at home?   Unrealistic or staged?  I doubt it.

I treat many patients who cut or otherwise injure themselves, and most of them know better than to tell the average doctor about it, because the average doctor will freak out.  Even psychiatrists.  They may get thrown in a mental hospital when being there would make their mental state even worse than it had been before they got there.  Who feels better being thrown in with a bunch of psychotic people?

Many of my patients have been abused and betrayed by almost everyone in their lives they were supposed to have been able to trust.  Yet when they are not completely open with a new doctor, who again is a complete stranger, they are accused of having pathological "trust issues."  In truth, they would have to be completely crazy if they did trust anyone implicitly after what they've been through.

When it comes to specific problematic or dysfunctional family interactions which trigger a patient's bouts of depression, panic attacks, impulsive acting out, or mood instability, in my experience people will not volunteer this information unless specifically asked about who says what to whom about whatever problem they bring to treatment.  It's a case of don't ask, don't tell.  If the therapist does not ask, they do not think to tell.

Since I was initially trained in psychotherapy by psychoanalysts, I was never trained to ask questions like, "What does your mother say about your being so depressed all the time?" or even "What does your father-in-law say about these fights you and your husband keep having? "  Once I started to ask questions like that, a whole bunch on new types of information I had never heard before came flowing out of patients.  The type of psychiatrist who calls all mood swings evidence of bipolar disorder never asks this type of question.

In the Medscape discussion, a patient jumped in added her two cents to the discussion about doctors believing everything they hear:

I am a survivor of domestic violence. My husband and I were going to marriage counselling. During counselling my disclosures about our marriage led my husband to decide that I had to be committed to our local hospital's mental health unit. He completed the necessary paperwork and told the psychiatric staff that he believed I had bipolar disorder with persecutorial delusions about him. The consulting psychiatrist believed him and his "proof" of my deteriorating mental health and I was given a confirmed diagnosis of bipolar disorder with persecutorial delusions. I was hospitalised for five weeks based on this confirmed diagnosis. During this time I was told that unless I took medication (zyprexa) I was not going to be discharged. When I contested and challenged the diagnosis, I was placed on an involuntary treatment order because I was so unwell I lacked insight into the severity of my unwellness.

I do not have bipolar disorder with persecutorial delusions. If the psychiatrist had not been so quick to diagnose and had had a watch and wait approach as well as performed a more thorough case history into my domestic situation and life with my husband, then I would not have been given this mis-diagnosis.

I would of course want to hear both sides of the story before I made up my mind about anything.  Shame on doctors who think they can read minds and perhaps that the only people who should not be believed are the ones who claim they are being abused.


  1. It seems to me that psychiatry is an illusion. There is the illusion expressed here that there is something called a real diagnosis, that family behavior problems are "mistaken" for a psychiatric diagnosis, someone may "appear" bipolar when in fact they are . . . something else.

  2. "Things are seldom what they seem
    Skim milk masquerades as cream"
    -----William S. Gilbert

    Actually, when a psychiatrist has enough information and the right information, psychiatric diagnosis is often very straightforward and highly reliable.

  3. Your discussion with psychiatrist was very interesting. I was thoroughly enjoying a lot. And both of the psychiatrists are great and they have good knowledge.

  4. Sometimes I just need a 'like' button for your posts :)