Monday, April 15, 2019

How Good Psychiatrists Evaluate New Patients

If you think you might need psychiatric medications, here's the minimum of what the doctors should cover in a GOOD evaluation. If they do not, FIND ANOTHER PSYCHIATRIST:

1. They should spend at least 45 minutes to an hour in the initial interview.

2. When asking about your symptoms, they should pin you down as to exactly when and in which psychosocial circumstances you experience them. To be relevant to any diagnosis, all symptoms should be present at the same time and significantly affect you over more than just short periods.

Major mood disorders such as true major depression and mania are grossly over-diagnosed nowadays. The symptoms of these disorders are pervasive: you have to have them nearly all day nearly every day no matter what else is going on in your environment. Major depressive episodes need to last for at least two weeks straight, while mania requires a whole week. While these “duration” criteria are arbitrary, they are in the diagnostic criteria to distinguish major mood disorders from emotional reactions to purely environmental changes or relationship problems.

During a major mood disorder episode, your reactions to everyday stress should also be completely different from your usual, baseline reactions (how you react to your environment when you are not in a mood episode). They should also be out of character for you - Jeckyl and Hyde territory.

Mood and anxiety disorder diagnoses can NOT be made definitively if you are actively using psychoactive substances. Intoxication with drugs like cocaine can, for instance, mimic mania.

Stressors can trigger a new mood episode, but once episodes happen, they take on a life of their own.

3. The doctor should do a psychiatric "review of systems" to ask questions to rule out (at the minimum) a history of mania, substance abuse, panic attacks, OCD, and self-injurious behavior. 

They should ask you about whether there is a family history (among blood relatives, not adoptive relatives) of psychiatric problems or substance abuse. They should also ask you for your medical history and medications you take to try to rule out medical reasons for your symptoms.

In particular, panic attack symptoms are often ignored or falsely classified as symptoms of a mood disorder.

4. They should take a COMPLETE psychosocial history covering your family constellation, parental behavior, any parental divorces and subsequent marriages, any history of abuse or neglect, how far you went in school, and a complete history of your employment and relationships.
This part of the history has almost disappeared from psychiatry, blurring the distinction between psychological reactions and major mental illnesses.

A history of adverse childhood experiences such as abuse, neglect, violence, substance abuse or infidelity by parents can put you at risk for personality problems, low moods, anxiety problems or many other psychological symptoms. Again, a traumatic environment can trigger chronic problems that medication can help, but psychotherapy is the more important treatment. Even if your psychiatrist only prescribes medication, he or she should still refer you to a therapist in these instances. A good psychiatrist will focus on ALL the relevant variables amenable to different treatments and not focus myopically on just your symptoms.

5. If you are having trouble focusing or concentrating, this alone does not mean you have “ADHD.” You can have this symptom due to stress, sleep deprivation, boredom, preoccupation with something, or a wide variety of other reasons. A good doctor will ask questions to rule out these causes rather than just throw dangerous stimulants like Adderall (a methamphetamine clone) at you. 

6. If medications are prescribed, they should tell you what the most common side effects are, and if there are any dangerous ones even if they are rare, and also tell you that if you think you are having an adverse effect, that you should call the doctor's office.