Bipolar versus Borderline: Disease Mongering Pill Pushers Stack the Deck

In my Psychology Today blogpost of 12/11/11, Bipolar or Borderline, I described how disease mongering, pill-pushing psychiatrists have done their utmost best to blur the distinction between the mood (affective) instability seen in borderline personality disorder (BPD) with the mood episodes characteristic of true bipolar disorder. 

This distinction is important because BPD is clearly a disorder of interpersonal relationships and behavior mixed in with a history of trauma and family dysfunction, while true bipolar disorder is a serious biogenic brain disease. BPD, while some of its symptoms do respond quite well to the right medications, should be treated primarily with psychotherapy, while bipolar disorder should be treated primarily with medication.

In the prior post I discussed the use of invalid symptom checklists in studies to exaggerate the incidence of bipolar disorder. They are also used by some incompetent psychiatrists to make diagnoses that justify snowing every patient who walks in the door with potentially toxic antipsychotic medication. In the June 2016 issue of the Journal of Personality Disorders, researcher Mark Zimmerman goes into some detail about exactly how corrupt researchers use slight of hand to distort their data (Improving the Recognition of Borderline Personality Disorder in a Bipolar World, pp. 320-335).

They are very good at it. And it matters. Zimmerman states: "Although BPD is as frequent as (if not more frequent than) bipolar disorder, as impairing as (if not more impairing than), and as lethal as (if not more lethal than) bipolar disorder, it has received less than one tenth [emphasis mine] the level of funding from the NIH [the National Institutes of Health] and has been the focus of many fewer publications in the most prestigious psychiatric journals."

And, Zimmerman points out, the difference is not due to just the fact that there were more drug studies for bipolar disorder. In fact, the amount of funding for the drug treatment of bipolar disorder was just a little more than 10% of the total.

As I have mentioned several times in this blog, self-report symptom checklists are meant to be screening devises. This means that if you are positive for bipolar disorder on the screen, it does not mean you have bipolar disorder. It means you should be evaluated further! Screening tests are designed to have a lot of false positives - people who come out as positive on the test but who do not actually have the disorder. In fact, the majority of people who screen positively do not have bipolar disorder.

Zimmerman specifically brings up the Mood Disorders Questionnaire (MDQ) that I discussed in the previous post. Get this: in one study by Frye and others in the journal Psychiatric Services in 2005, the authors found that one half of the patients who were positive for bipolar disorder on the MDQ were not diagnosed with bipolar disorder by the treating clinician.  

Their conclusion? They said the clinicians "failed to detect" or "misdiagnosed" bipolar disorder in these patients! Actually, the exact opposite is far more likely: it sounds like the clinicians' judgments tended to be correct.

Frye and others then went on to state that these patients were "inappropriately treated because they were given antidepressants instead of mood stabilizers." Again, exactly the wrong conclusion to draw from the authors' own data. Yet they went on to say that this completely false conclusion was "worrisome." Some of us would call this real chutzpah.

Bipolar, my ass researchers love to talk about the bipolar "spectrum," based on the crazy logic that if a given symptom appears slightly similarly in two people, they must both have a version of the same syndromic psychiatric disorder. Zimmerman asks why no one talks of a borderline spectrum, when clinically, many patients are diagnosed as having borderline traits. This means that out of the nine criteria, of which you are required to meet any 5,6,7, 8, or all nine to qualify for the diagnosis, the patients may only have three or four. 

In fact, as reported in the July issue of the American Journal of Psychiatry (Vol. 173, pp. 688-694), Zanarini and others followed 290 patients with BPD closely over 2 years. They found that "...the symptoms of borderline personality disorder are quite fluid..." This means that they come and go over time. This was particularly true for acute symptoms like self-mutilation. Therefore, people with the disorder may frequently go from 5 symptoms to 4, and suddenly they don't "have" it anymore - unless and until the 5th symptom recurs!

In actual reality, he said redundantly, those people who exhibit three or four of the nine symptoms look a lot more like those folks who have five or more than they do like those folks who have none of them. Now that sounds like a "spectrum" to me.

Adventures in the Veterans' Hospital Mental Health Clinic - Part II

Continuing on from my post of 3/17/15 on the Kafkaesque nature of the VA bureaucracy, their motto seemed to be, "If we find a problem in the system, we'll come up with a ridiculous solution that may make the problem even worse. Or at the very least, create a whole new set of problems."

For example, not too long ago there were a couple of serious foul-ups at the VA Memphis hospital that were caused by patients being mis-identified by staff and given the wrong treatment. This sort of thing can have disastrous consequences, of course, and it happens from time to time in almost all hospitals. It is quite a serious issue. Of course, in these cases dire consequences are most likely to result  with surgery or in a busy emergency room; such events are fairly rare in outpatient clinics.

The VA solution: Every doctor was instructed to verify every patient's full social security number and full name immediately at the beginning of every single appointment. We were told to do this, not just for patients we did not recognize, but even for our regular patients who we have been seeing for years! And we were told that we had to document that we had done this - again every single time - in the patient's electronic medical record (EMR). No one anywhere else does this.

That may seem like a small although illogical request that wouldn't take much time. The trouble was, we were asked to document a whole bunch of other things almost every visit. Most of these things were completely irrelevant to the visit at hand. For instance, there are so-called "clinical reminders" to ask about certain information at most visits whether it concerned the reason for the patient's visit or not (example shortly). 

With limited time to see each patient and to document the relevant information in the EMR, this added a significant amount of time to a visit that would then not be available to actually evaluate the patient's progress for the problem that was being actively treated.

Most of the clinical reminders were checklists, about which I have complained many times on this blog. One particularly ridiculous clinical reminder was a requirement to perform a depression screening checklist, the PHQ-9. This is just what it says it is - a screening test to see who should be evaluated further for depression. 

It is meant to be used by primary care docs and other non-psychiatric physicians to determine who should be referred to a psychiatrist for these further evaluation, and who does not need one. It is meant to cast a wide net, meaning a positive test does not mean that you have a clinical depression - only that you might and should therefore be screened further.

The VA wanted the psychiatrists to ask their patients to fill one out! If a patient is already being evaluated by a psychiatrist, the purpose of PHQ-9 is no longer operant, so filling one out is completely pointless and an utter waste of time. Unless, of course, someone is such a bad psychiatrist that they think a psychiatric evaluation does not include an evaluation for depression.

I refused to do the PHQ-9's, because I perform a complete bio-psycho-social psychiatric evaluation when I first see a new patient, and I was not going to short change my patients by further shortening our already limited time together by asking questions I already knew the answer to, or was about to go into far more detail about than is possible with a PHQ-9.

Actually, there was at least one psychiatrist on staff who did not do a complete evaluation of every patient. Because this psychiatrist did not make waves, that clinician was allowed to practice what I consider to be piss poor psychiatry for years. Then the doc left. I will discuss what happened in that situation in Part III of this post.

Faking Psychiatric Conditions for Fun and Profit

The nurse was on to McMurphy's ruse...because she was actually paying attention

A story from the New York Times on  August 27, 2014 caught my eye:

“Ex-Police Officer Pleads Guilty to Playing Role in a Disability Fraud Scheme  By JAMES C. McKINLEY Jr.

A former New York City police officer accused of playing a major role in a scheme to defraud the Social Security Administration pleaded guilty on Wednesday and agreed to testify against his co-defendants. Prosecutors said that the former officer, Joseph Esposito, was one of four people who concocted a scheme that bilked the federal government out of more than $27 million. 

The group allegedly helped scores of police officers, firefighters and other city workers obtain disability benefits by feigning mental illnesses, in some cases by falsely claiming they had been psychologically scarred by the terrorist attacks on the city on Sept. 11, 2001…

Court papers… described Mr. Esposito’s role as pivotal. He recruited many of the people who applied for the benefits and introduced them to three others accused of helping to run the operation …referred most of the applicants to two psychiatrists for treatment and to establish a year’s worth of medical records. On several telephone calls recorded by the authorities, Mr. Esposito was captured coaching applicants on how to mimic the symptoms of depression and post-traumatic stress when being examined by doctors…

With diagnoses and treatment records from the doctors in hand, Mr. Hale and Mr. Lavallee would complete and submit applications to Social Security, using stock phrases like “I don’t have any interest in anything” and “I am up and down all night long.”

Psychiatric symptoms cannot be measured objectively under the best of circumstances.  Doctors must rely on patients' self reports or on how they appear in the examining room. And people can be excellent actors in situations like this without ever having taken an acting lesson in their life.  Faking a psychiatric syndrome is in most cases extremely easy to do.

So it does not necessarily follow that a psychiatrist is not doing his job correctly if he or she is deceived into thinking a patient meets DSM criteria for one disorder or another.  This is especially true when a patient is only seen in the doctor’s office, where an appointment may last a relatively short time. It is obviously more advantageous if a psychiatrist has a way of observing patients when the patients do not realize they are being observed.  In a hospital setting, for example, patients may let down their guard during a quiet afternoon spent socializing with other patients, and not realize that a nurse is watching them out of the corner of her eye.

However, the job of the schemer/faker has gotten considerably easier, whether they are trying to fake a disability claim, looking for an amphetamine prescription, or even trying to enroll in a study for which subjects get paid. This is because diagnostic interviews have gotten shorter and shorter, and doctors have begun to rely on the use of shortcuts such as symptom checklists – two things that I have been ranting about frequently on this blog. 

Under these circumstances, dishonest patients do not have to worry much about being caught in an apparent contradiction, nor do they need concern themselves with describing their symptoms in detail in a way which might seem to the examiner atypical for the condition they are faking. The doctors ask no follow-up questions, the answers to which might then raise suspicions that they are possibly being duped.

The use of the all important follow-up questions is particularly vital in sorting out the clinical significance of a psychiatric symptom that may seem to be present. A good psychiatrist functions much like a good investigative news reporter.  He or she can look for signs that the patient does not know exactly what the doctor needs to know, is exaggerating symptoms, or is possibly making some unspoken assumptions. The doctor can then ask for further clarification, which is an excellent technique for unmasking possible fabrications or half-truths.

Another recent trend that makes it easier for a patient with a hidden agenda to fake a psychiatric disorder is the tendency of some doctors to type away on an electronic medical record while the patient reports his or her symptoms - instead of making eye contact with the patients and observing them carefully while they talk. Cues to fakery that involve facial expressions and body language will of course be missed.  Not to mention that the doctor's attention is being split between two tasks instead of just one, making all clues to dishonestly less likely to be noticed.

Of course, even a doctor who does a real and complete diagnostic interview the way it is supposed to be done can still be faked out. But doctors who do not do one are far more likely to be duped. Apparently, many of them do not really care if they are – as long as they get paid.

Is Your Psychiatrist Committing Malpractice Even if Doing What a Lot of Other Psychiatrists Are Doing?

My malpractice carrier, which is physician owned and operated, recommends taking one of their seminars or online courses on different aspects of medical malpractice every year, and gives those policy owners who do a 10% discount on their yearly premium. 

The course I took this year was on misdiagnosis.

The course was not really geared to psychiatrists at all, but it seemed to me that the general advice still applies to them. However,  in my experience the advice is not clearly being followed by a lot of my colleagues these days. If these recommendations are indeed valid, and I certainly agree that they are, a lot of psychiatrists are getting away with gross negligence. 

Statistics show, by the way, that doctors are actually far more likely to get sued for something they did not do wrong than they are to get sued for actual malpractice. Isn’t that bizarre?

Some of the advice in the malpractice course concerns two major criticisms of my colleagues that I have written about extensively on this blog and in my last book: relying on symptom checklists, and relying on a diagnoses made by a prior clinician. Truly frightening.

So, as a public service, here’s some information from the course that psychiatric patients might find useful if they are considering suing a psychiatrist for malpractice. From MedRisk (Medical Risk Management, Inc.).

Misdiagnoses were more likely to be considered negligent in malpractice suits. Misdiagnoses were more than three times more likely to result in serious patient injury than medication errors.

2.      Multiple case law decisions have consistently held that the patient has no duty to volunteer information the physician does not ask about, and the patient’s only duty is to answer the physician’s questions honestly. (A smoker actually has no duty to tell his cardiologist about the smoking if the cardiologist does not ask!)

3.      Review any written history questionnaires with the patient to make sure the information is accurate. Patients who are sick or in pain can’t be relied on to even read the questions carefully, let alone provide thoughtful answers. Many patients will simply respond with a “No” to all prior diseases without reading the list and some patients, as discussed below, may not even be able to read or understand the questions. For example, the patient with a known history of high blood pressure may answer “No” when asked if he has ever been diagnosed with hypertension simply because he doesn’t know that they are the same thing. So make sure that your questionnaires are worded as simply as possible. Even then, review the responses verbally with the patient and make sure that you really do have a useful medical history. 

      

      Most healthcare instructional materials provided to patients are written on a 10th grade reading level or higher. Yet the reading level of the average patient is 4.6 grade levels below the last year of school completed, which means that a typical high school graduate reads at around an 8th-grade level. Further, the average Medicaid recipient reads at less than a 6th grade level, with more than one-third reading below the 4th grade level.

4.      Hear the patient out while taking the history and do not interrupt. Physicians are often overworked, overbooked, and scrambling to stay on schedule. This can leave them anxious to get to the point of a patient visit. One study found that physicians on average interrupted patients only 18 seconds into the explanation of the reason for the visit. This is significant because patients typically have a list of several complaints or observations they would like to discuss, yet rarely get beyond the first or second before being interrupted. Cutting the patient off before you’ve heard him out is called “premature closure,” and the main problem with this approach is that it assumes that the presenting complaint carries the most medical significance.

This is often not the case because the patient experiencing multiple symptoms may not know which are the most important, nor which may be related to the same underlying cause. For example, the patient who reports transient blurriness in her right eye may not realize that the simultaneous tingling sensation she feels in her right arm and leg are related. Premature closure typically involves a patient with a serious but uncommon diagnosis who presents with symptoms suggestive of a less serious and more common diagnosis.  

Contributing to premature closure is a general human tendency to hear what we expect to hear, and mentally filter out as extraneous any details that we don’t expect. Fortunately, the main assumption underlying premature closure—that patients will talk endlessly if allowed—appears to be incorrect. Several studies have found that patients who are allowed to list all their concerns without interruption rarely speak for more than two minutes. Allowing the patient those two minutes not only prevents premature closure, but can actually save you time by allowing you to focus on the most important symptoms first. It also avoids those “Oh, by the way…” conversations in which the patient brings up a new problem just as you’re headed for the door.

And finally:

5.      Every doctor owes a duty of making an independent assessment of the patient, utilizing the full range of his or her clinical skills, regardless of whether you’re a primary care provider or a sub-specialty consultant. If you’re an FP [family practitioner] and receive a specialty ob-gyn report informing you that a 60-year-old woman who had a hysterectomy 15 years ago is pregnant, you’d obviously recognize that you’d received the wrong patient’s report or that some other mix-up had occurred. Yet far less blatant errors occur all the time in the exchange of patient information, and you should always be mindful of that possibility any time the specialist’s opinion doesn’t fit your clinical finding or the patient fails to respond to treatment as expected.

Clearly, the same can be said for not entirely relying on the diagnosis of some other practitioner even  in the same specialty, who may or may not have done a good diagnostic workup, but instead doing one’s own independent assessment. If a  psychiatrist prescribes something to you after initally talking to you for just fifteen or twenty minutes, find another doctor.

The Deterioration in Quality and Usefulness of the Notes Written by Psychiatric Nurses

The hospital notes of psychiatric nurses are starting to be as unrevealing of the patient's true condition as the notes by psychiatrists. Both types of notes are relying more and more on useless symptom checklists. As my friend James Woods observed, using a symptom checklist to make a diagnosis is only slightly more accurate than throwing darts at a dartboard - blindfolded.

Whenever a psychiatrist sees a new patient who had been treated by another clinician in the past, it is usually standard operating procedure for the doctor to obtain any prior medical or hospital records that pertain to that patient’s case. However, an ethical psychiatrist does not rely completely on another doctor’s diagnosis or treatment, but does his or her own evaluation to form an opinion. 

The previous doctor might have had things completely wrong. The former chairman of the academic department in which I was the residency training director, Dr. Neil Edwards, used to tell residents in training that the evaluation of each patient new to a clinician should take into account two different possibilities: first, that any prior clinician was competent, thorough and correct. Second, that the prior clinician was none of these things. 

In order to judge the diagnosis made by a mental health professional from the medical records, there has to be more than just a diagnosis on the chart or a quick “mental status” exam from one or two points in time. There has to be a narrative description of the patient. Particularly in a psychiatric hospital setting, there should also be a description somewhere in the chart of the patient’s ongoing behavior on the ward, particularly when the patient is not aware that he or she is being observed, and any major consistent changes in that behavior over time as treatment progresses.

To understand why this is important, let me relay some personal experience. I worked for a time in the main psychiatric emergency room in Memphis, from which many patients were referred for psychiatric hospitalization. After having evaluated a patient in the ER, I would later see the same patient in the hospital on weekends, when I was covering a service for the doctors who were in charge of the patient in the new setting. I would review the patient’s chart for the events and subsequent evaluations that had occurred since admission. One thing I witnessed time and time again – and not just with trainees but with the attending faculty as well – was quite striking. 

In the ER, some patients looked very depressed and showed all the signs (observed characteristics) and complained of all of the symptoms of clinical major depressive disorder. Their movements and speech were slow (psychomotor retardation), and they complained of chronic and persistent changes in appetite, sleep, pleasure, energy, and concentration. Since the patient seemed to meet all of the necessary DSM criteria, the diagnosis of major depressive disorder was therefore made by my resident, and I concurred.

However, in many cases in which I saw the patient in the hospital the very next day, or heard a description of the patient’s behavior on the ward by the nurses on the day following admission, an entirely different picture emerged. The patient was observed to be actively socializing with other patients, friendly and talkative on approach, speaking with normal rate and volume, sleeping on hourly bed checks (although they often had been given a sedative), and eating 100% of served meals!

One major characteristic that distinguishes true major depressive disorder from other types of depression is that its symptoms do not evaporate overnight, nor do they disappear merely because of a change of venue for the patient. They persist and are present in all environmental contexts. They can get to the point where a patient could win the lottery but not crack a smile. If symptoms change radically with a change in venue, then the primary problem for the patient resides in the venue, not in his or her mental disorder.

Clearly, everyone’s initial diagnostic impression of these patients – including my own – was incorrect. 

Yet surprisingly, the patients’ diagnosis was almost never changed during the entire course of their hospitalization. Their admission and discharge diagnoses were identical. Furthermore, they had been given treatments that patients who actually had major depression would be given.

Were my observations of this phenomenon biased in some way? Perhaps not changing a diagnosis in the light of new and conflicting information was something peculiar to doctors practicing in academic settings or only those practicing in Memphis, the city in which I was located. Possible, but not likely. How do I know?  Well, in over 30 years of practice, I have had the opportunity to review medical records of patients who had been psychiatrically hospitalized all over the United States. 

Nowadays, I often do not even bother to even send for hospital records, for they have become next to worthless for understanding a patient's condition. In the doctor’s initial evaluation, there would be no information about the time course, pervasiveness, or persistence of any symptom the patient was alleged to have had. There might be a "description" of symptoms that would consist of meaningless terms such as  “paranoid” or “suicidal” without any explanation of what the term meant as applied to the particular patient, or the context in which it occurred. Did “paranoid” mean delusional, or merely distrustful? No information.

With electronic medical records, I often have access to the notes and evaluations of several previous clinicians. Often no “target symptoms “ are described when a patient is put on a medication, and there is no information later on about what, if any, symptoms, had gone away in response to treatment. No way to know if the patient should have stayed on the medication. Sometimes the meds would be changed, but no reasons would be given for doing so. Did it not work? Or were there intolerable side effects? Or what?

With hospital records, I used to overcome the problem of physicians’ notes lacking any indication of how the patient was behaving on the ward by looking at the nurses’ notes. They used to actually describe such things. The patient might be noted the day after admission to eat, say, 100% of meals, be up and about socializing on the ward, sleeping on one hour bed checks, and pleasant and appropriate on approach.  If such a patient had been diagnosed as major depression or manic by the doctor the day before, I would know that this diagnosis was incorrect.

Imagine my reaction when I recently learned that the major local psychiatric hospital in my area, which is a haven for manufacturing bipolar disorder diagnoses where none exist, was instructing its nursing staff on what and what not to include in its nursing notes. I thought I’d better take a look at them to see what was being included and what was not.

It was far worse than I thought. There were very few narrative nurses notes at all! The main part of the nurses' notes consist of  a checklist which basically completely omitted the type of information I was looking for.

I asked a patient about it. She told me that the nurses would line up all the patients on their ward at certain times of day, take their blood pressures and other vital signs, and ask them if they were suicidal or not. The patient told me that the nurses spent almost zero time observing them on the wards!

I really had to look at even the checklists very carefully to glean anything about how the patient was behaving. Another patient was diagnosed as bipolar, but even on the checklist, the patient's energy was marked normal, affect was marked appropriate, and mood was checked "euthymic" (normal). Bipolar, my ass.

There was also a separate sheet with observations allegedly made every 15 minutes, which of course was inconsistent with what my other patient told me about how often they were closely observed. The patient's behavior on the sheet was again not a narrative description but a number with each digit defined so generally as to be diagnostically meaningless.  Even then, this patient was noted to be sleeping throughout the entire night.

To be fair, there were some narrative notes scribbled on the back of these checklists, often written by a psychiatric technician and not a nurse. Many were illegible, and they contained fairly minimal information. Even so, an allegedly bipolar patient was described as "isolating to room frequently."  [How frequently? Why? In this case the patient later told me that there was a specific reason for going to her room that had nothing to do with a mood disorder], "Pleasant mood, appetite good," and "no distress noted." [Bipolar? Really??]

What is the hospital trying to hide? You can bet that somehow limiting the validity of the information on the patients' charts helps them to maximize their reimbursements from insurance companies - perhaps hiding the fact that they want their doctors to diagnose patients with something serious rather than something the insurance companies might question. Patient welfare be damned. 

Counting Symptoms that Don’t Count, Part II: Compared to What?

In my blogpost of July 24, 2010, Counting Symptoms That Don’t Count, I wrote.

“So what does a doctor who spends so little time with a patient do to save time? I mean besides completely ignoring the patient's relationships, history of trauma, humanity, etc…Well, one thing they can do is ask only about symptoms, and blindly accept the patient's yes or no answer without even checking to see if the patient understands the difference between a transient mood state and a psychiatric symptom. Better yet, before the doctor even sees the patient, he or she can have the patient fill out a symptom checklist, and base his diagnosis entirely on that. (Of course, his secretary could make a diagnosis doing that, so the patient really wouldn't even have to talk to the doctor at all).”

The inappropriate use of self report tests designed to screen patients as actual diagnostic instruments has become even more of an issue than ever. As you may recall from earlier posts, such instruments are purposely designed to cast a wide net so as not to miss someone in need of treatment, and as such, they snare many patients who do not, in fact, need treatment. 

As managed care is tightening its ever present grip, full psychiatric diagnostic interviews are being marginalized. This is especially true in the so call “collaborative care” models, in which psychiatrists merely advise primary care physicians without necessarily seeing the patient themselves. 

Fellow blogger George Dawson, M.D. beautifully describes the problems with the use of a depression screening instrument in wide use called the PHQ-9:  “…let's talk about what is really happening here.  This is all about a patient coming in and being given a PHQ-9 depression screening inventory…  It generally takes most patients anywhere from 1 - 3 minutes to check off the boxes.  Conceivably that could lead to a diagnosis of depression in a few more minutes in the primary care clinic.  At that point the patient enters the antidepressant algorithm and they are they are officially being treated [they may be given an antidepressant on the basis of the pHQ-9 results alone - DA]. The care manager reports the PHQ-9 scores of those who do not improve to the "supervising" psychiatrist and gets a recommendation to modify treatment."

No determination of whether the symptoms are clinically significant. No determination of whether the symptoms reported are merely relatively normal reactions to adverse environmental events. No nothing.

To appreciate why symptom checklists are so problematic, I need to discuss something called a Likert Scale. A Likert Scale asks the patient to “rate” a symptom by level of severity, frequency, importance, or how strongly the test taker agrees with a statement. There is usually a 4 to 7 point scale with a  number attached.  Examples:

Not at all - 0

Several days - 1

More than half the days - 2

Nearly every day -3

(the PHQ-9 Likert Scale)

Very Frequently = 5

Frequently = 4

Occasionally =3

Rarely = 2

Never  =1

Not difficult at all = 0

Somewhat difficult = 1

Very difficult = 2

Extremely difficult =3

Very Important = 5

Important = 4

Moderately Important =3

Of Little Importance =2

Unimportant =1

Notice that the questions are asking the test taker to make a judgment about a symptom, but do not really define each level. It is therefore up to the test taker to decide whether the symptom occurs “often” or is “difficult” compared to some standard. But compared to what? Most people will use their own experience as reference points, and apply the terms according to this subjective standard.

So how is this a problem? Well, for depression inventories, most people have never seen someone with a severe melancholic depression who is thinking, moving and talking at a snail’s pace and who is totally and constantly overwhelmed with his or her depression all day every day for weeks at a time.  

Having never seen this, the average person does not know how bad depressive symptoms can be – unlike an experienced psychiatrist who has seen the whole gamut of depressed feelings. They therefore will not compare themselves to that, which is actually the relevant comparison!

So each test taker is, in effect, creating his or her own scale. What seems like "often" to them might not seem like very often at all to someone else. This makes the results next to meaningless for making a real diagnosis.

For those interested in statistics, the issue was neatly summed up by John Knight, a commenter on a Psychology Today Blog Post that criticized another post I had written.  He wrote:

“Firstly, there is nothing more subjective than self-reporting. How on earth can we treat what a client reports as objective data? Can any patient really detach themselves and report their... 'status' objectively, and interpret their symptoms and place scores on a Likert-type scale in the same manner as everyone else? What about the issue of the relationship to the practitioner? Can a patient be trusted to report objectively without trying to spare the practitioner's feelings? Or the opposite - what if they are annoyed and want to give negative feedback to someone they don't like?

Secondly, these Likert-type scales are often being processed as interval-level data rather than ordinal data. For the statistically uninitiated, ordinal data generally consists of "an arbitrary numerical scale where the exact numerical quantity of a particular value has no significance beyond its ability to establish a ranking over a set of data points" (thank you Wikipedia), whereas interval data will be something like degrees, metres, kilometres, and so on.

A Likert-type scale is ordinal data, but weak arguments and statistical trickery are being employed to treat it as interval data, which is easier to process and looks more scientifically impressive.

To lay off the accountant language for a moment, many CBT practitioners are treating patient self-reports with the same kind of measurable, real-world objectivity that one would treat degrees celsius, metres, kilometres, and so on. That is quite simply disgusting, and should trouble the conscience of any scientist willing to employ the method.”

Another problem is that instruments like the PHQ-9 ask questions about how many days a week a person experiences a symptom, but do not ask how long the symptoms last on a given day when present, let alone about the circumstances in which a symptom makes an appearance.

Let’s look at the questions, and I’d like the reader to envision two scenarios. The first is the melancholic depressive described above. The other is a man who gets involved and preoccupied with his duties at work and feels fine there, but every night after he gets home he becomes embroiled in a continuing conflict with his wife, who is threatening divorce, and only then starts to become extremely upset. 

I think the reader will see how it is quite possible that both of these very different individuals might answer the PHQ-9 questions in almost the exact same way, and come out with identical scores. The first would benefit from an antidepressant. The other would not, and probably needs marriage counseling instead.

PHQ-9 Patient Depression Questionnaire

Over the last 2 weeks, how often have you been bothered by any of the following problems.

Not at all - 0

Several days - 1

More than half the days - 2

Nearly every day -3

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself—or that you are a failure or

have let yourself or your family down

7. Trouble concentrating on things, such as reading the

newspaper or watching television

8. Moving or speaking so slowly that other people could

have noticed. Or the opposite - being so figety or

restless that you have been moving around a lot more

than usual

9. Thoughts that you would be better off dead, or of

hurting yourself

add columns

TOTAL:

10. If you checked off any problems, how difficult have these problems made it for you to do your work take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Copyright © 1999 Pfizer Inc.

Oh gee, look at who came up with this scale. A drug company. How convenient!!

Is Your Psychiatrist Paying Attention?

In my post of 2/24/2010, Counting Symptoms that Don't Count, I discussed how many psychiatrists these days are taking huge shortcuts in order to squeeze as many patients into an hour as they possibly can. I described how they are focusing just on symptom counts without trying making the slightest effort to ascertain whether or not the symptoms in question are clinically significant for a particular diagnosis, or whether they might require psychotherapy rather than drug treatment.

As I have pointed out many times in this blog, in order to make such a determination, the doctor has to take into account the timing, pervasiveness, persistance, and subjective quality of a symptom. The psychiatrist has to know what other symptoms are present at the same time and at different times. Most importantly, the doctor has to know something about the psychosocial context of a symptom.

One of my partners reported a particular glaring example of what can happen when this is not done: A patient with no previous psychiatric history became depressed right after finding her husband in bed with another woman.  Her "depression" was characterized, not surprisingly, mostly by anger and preoccupation with the discovered affair.  Nevertheless, when she came to the attention of a psychiatrist, he diagnosed her with "major depressive disorder."  Really?  I mean, really???

Another time saving "convenience" is for the doctor to write down the information that the patient is relaying during an interview on the patient's chart, using either pen and paper or a computer, as the patients speaks. This not only saves time, but solves a second problem: Some insurance companies do not want to pay for a doctor's time unless it is spent face to face with the patient. Even time spend reviewing the patient's record and writing down all the information that insurance companies demand in order to pay the doctor is supposed to be donated, I guess. So instead of writing a progress note after the patient leaves, it is written with the patient still in the room!

So, aside from wasting the patient's time while the doctor does that, what's wrong with that?

Well, I'll tell you.  When a doctor is writing or typing away on a computer, his or her attention is split between doing that and observing the patient. Often a patient's body language or facial expression can give a doctor a clue that what the patient is saying may not be completely accurate or may not be the whole story, so that the doctor then needs to ask for clarification with follow-up questions. When the doctor is staring at a chart instead of the patient, that is probably just not going to happen.

Even more important, patients will often mutter vitally important information quickly and in passing, or even under their breath. This is particularly likely to happen if the information patients are relaying is troublesome to them in one way or another, such as reporting things they are ashamed of. If the doctor is not paying close attention, he or she will literally not hear it!

In my book, How Dysfunctional Families Spur Mental Disorders, I describe in detail a videotape of a psychiatry trainee doing a diagnostic interview in front of two senior faculty members in order to practice for her upcoming oral boards. In the videotape, a real patient was used. During the interview, the patient stated in passing that she had been repeatedly molested by a close relative. In fact, the matter even ended up in court. After the interview, the examiners both said that they "suspected" that a trauma history was "likely" in the patient.

There were three doctors in the room, all of them preoccupied with the trainee's performance.  All three of them either missed or forgot that abuse was not only likely, but had actually been mentioned!

Counting Symptoms that Don't Count

A horrible trend has been taking off for the last decade in psychiatric offices across the country. As fees for psychiatrists were ratcheted down by managed care insurance companies, especially for psychotherapy, psychiatrists have tried to keep up their income by becoming primarily prescription writers and seeing as many patients per hour as they possibly can. This has let to the infamous ten or fifteen minute "med check." In this short period of time, the context of the patient's life experiences as it affects a patient's psychological condition is seldom even evaluated, let alone taken into account, in making a determination of which medications and dosages are appropriate for a particular patient.

The time squeeze has also adversely affected the patient's initial diagnostic evaluation. A comprehensive evaluation takes at least forty five minutes, even if the doctor only superficially touches on all the relevant information that needs to be elicited from the patient. Initial evaluations now are often squeezed into a half hour, which often includes the time the doctor has to write his note, return phone calls, and/or go to the bathroom. If any reader plans to see a psychiatrist who does not schedule an hour for a new patient, I would advise that reader to run as fast as you can in the opposite direction!

So what does a doctor who spends so little time with a patient do to save time? I mean besides completely ignoring the patient's relationships, history of truama, humanity, etc. (One of my patients reported being screamed at by his last psychiatrist, "I don't want to hear about your mother!! I just do meds!"). Well, one thing they can do is ask only about symptoms, and blindly accept the patient's yes or no answer without even checking to see if the patient understands the difference between a transient mood state and a psychiatric symptom. Better yet, before the doctor even sees the patient, he or she can have the patient fill out a symptom checklist, and base his diagnosis entirely on that. (Of course, his secretary could make a diagnosis doing that, so the patient really wouldn't even have to talk to the doctor at all).

So, is it not true that the DSM, the diagnostic Bible in psychiatry, just lists symptoms as diagnostic criteria, and says how many of them you need to make a given diagnosis? No! It requires a doctor to also make a clinical judgment about the diagnostic significance of any symptom a patient reports. This involves asking follow up questions like a good newspaper reporter. Just because a patient reports staying up all night without feeling tired for seven days in a row does not mean that the patient also remembered to report that he was sleeping during the day, or was on a cocaine binge.

To illustrate better what I mean, I would like discuss the contents of an article called Avoiding Diagnostic Deficit Disorder in Bp Magazine. Bp Magazine is a periodical about patients' experiences with bipolar disorder. The disorder, which used to be called manic depression, is characterized primarily by distinct periods of severe mood elation and other periods of severe depression, separated by normal periods (euthymia) in between.

I was not able to find much online about the publishers of this magazine, and what I found may be faulty, but apparently the publisher, Green Apple Courage Inc., was founded by one Bill MacPhee, a patient with schizophrenia who was finally stabilized on medication and became productive again.

The primary advertisers for BP Magazine were listed on one web site as "Platinum sponsor Pfizer Inc. and Gold sponsors Bristol-Myers Squibb Company, Otsuka America Pharmaceutical, Inc. National mental health association advertisers include the Child and Adolescent Bipolar Foundation, Depression and Bipolar Support Alliance, Mental Health America and the National Alliance on Mental Illness." I started getting the magazine in the mail for free unsolicited, which usually means a pharmaceutical company is paying for mailing the publication to psychiatrists like me. Draw your own conclusion about whose interest the magazine might be best serving.

Anyway, the article expresses concern that bipolar patients might be misdiagnosed with something else, when the real danger nowadays is that a patient with something else will be misdiagnosed as "Bipolar II," which in my humble opinion is part of the Bipolar, My Ass Spectrum Disorder.  So it advises potential patients to tell their doctor about symptoms such as agitation, impulsivity, racing/obsessive/cluttered/busy thoughts, hypersexuality, hyperbuying, euphoria, decreased need for sleep, and use of alcohol or other agents to relax.  It advises that they report these other symptoms last: depression, anxiety, panic, and trouble concentrating.

The article neglects to point out the fact that in mania, these symptoms all have to occur at the same time, and be totally atypical for the way the person normally functions. I mean, true bipolars are like Jeckyl or Hyde (not both at the same time) for an extended period of time.  They do things while manic that are totally out of character for them. These characteristics of the symptoms are absolutely essential for determining their diagnostic significance.

We speak of the three p's: pervasiveness, persistence, and pathological.  The symptoms of mania in particular have to affect every aspect of the person's life regardless of the person's changing external circumstances, they have to continue for a full week at the very minimum, and they have to cause significant distress or impairment.  (Hypomania, hallmark of bipolar II, only has to last four days.  Not four minutes, four days.  It is the only condition in the entire DSM that does not require distress or impairment).  One also has to take into consideration the state of a patient's current relationships in order to rule out normal reactive mood changes.

But wait, there's more!  Every symptom that the article recommended reporting first is non-specific.  That means that each and every one of them can be symptoms of several different psychiatric disorders, depending on their other characteristics, or they may just be normal personal variants or the result of having a bad day.  I mean, anyone here ever go on a spending spree and buy more than they should have?  The nation's huge credit card debt screams out that this is hardly a phenomenon only seen in manic or hypomanic patients.

Let's take irritabilty, for another example. It can be a symptom of mania, but it can also be a symptom of major depression, dysthymia, generalized anxiety disorder, panic disorder, a personality disorder, the abuse of a variety of different drugs and alcohol, side effects of medications, having just had a big fight with your mother, or just feeling irritable for that day for no particular reason at all.

Now, the doctors who think everyone who comes to them is bipolar and is in serious need of drugs object to the DSM bipolar criteria for duration of symptoms.  That may be a legitimate criticism, but so far there is not a single shread of evidence linking brief mood swings like going into a rage to true bipolar I disorder.  The doctors pushing this idea basically pulled the idea that they are related out of their asses. 

To prove this, however, they do studies in which they diagnose people who do not meet the duration criteria for mood episodes as "bipolar not otherwise specified (NOS)," which is a diagnosis that is listed in the DSM.  What the NOS designation is supposed to be used for is people who just barely miss DSM criteria, like someone having manic symptoms for six rather than the required seven days. It is not supposed to be used for people who miss the criteria by a country mile, like a person having a ten minute mood episode.  I would call the tactic of using the NOS category for patients like that as Nothing Other than Stupid.

They then do studies which include patients that they have diagnosed with their version of the NOS disorder, thereby gathering a sample of subjects that contains a certain number of people who have ten minute mood swings.  They then look at their overall sample to see how many of their "bipolars" have this symptom, and voila!  A significant percentage do, therefore "proving" that bipolars can have ten minute mood swings.  If you don't understand the term circular argument, you can look up the term circular logic.  It might say that circular logic means the same as circular reasoning.  If you don't know what circular reasoning means, you can look that up and find out that it means the same as circular argument.

One blog reader asked me why I do not believe in brief mood swings.  Of course I believe in them.  They are just not symptoms of bipolar disorder.