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CLPsych has an interesting post on a study that found that among patients with Medicaid in Oregon who were prescribed antipsychotic medication, only a minority actually had a diagnosis of a psychotic disorder or bipolar disorder (15% vs 27%). The rest had diagnoses of depression, anxiety, or PTSD. I think I’d like to add to this the fact disorders are often diagnosed for the medication as I’ve written about before (On Diagnosis, Symptoms, and Medication; Diagnosing for the Medication). In other words, there are times when the diagnosis is given in order to justify the medication that is prescribed. This doesn’t happen all the time, but it does happen.
http://clinpsyc.blogspot.com/2008/09/atypical-antipsychotics-for-all-oregon.html
Some really are….I remember one man told me he showed up to his psychiatrist appointment dressed as a full blooded Apache Indian, headress of feathers and all. Others, well seemed to meet the criteria, but were not as dramatic. One woman I worked with appeared, to all intents and purposes, to be bipolar. However, we discovered over time that her mood variation was driven by anxiety and an underlying low self-esteem. She was able, over time, to learn how to manage her moods more effectively, and eliminate destructive impulsive behavior. It took a couple of years….but she is completely recovered. She called me a couple of years ago to tell me that things were still going well, and she was practicing those things we talked about. Some folks with Bipolar Disorder REALLY need medication, but they believe that they can manage it on their own. I’ve not seen that be possible with the more severe forms. With the more severe forms, you can make yourself probably 50% better by deeply examining the psychological factors, but the other 50% comes from medication.
With milder forms, some things make a difference. Developing a consistent routine is one. Go to bed at the same time, and get up at the same time in the morning. Stay away from illicit drugs (marijuana is the most frequent). Make your patterns as routine as you can. Eat 3 meals at the same time each day. In other words, you reduce the factors that increase the instability of your mood. It might be certain types of relationships, or certain types of thinking. There might be unconscious factors that can only be discovered with the help of a trained psychoanalyst. Or psychologist with some understanding of the unconscious mind. Take Omega-3 fatty acids (most often fish oil), vitamin B12 (preferably sublingual), and melatonin (it may take 2 or 3 pills) to help normalize sleeping patterns. The melatonin is to be taken a half an hour before going to sleep.
Some of the best quality supplements can be obtained from http://www.mercola.com. The Krill oil supplements are the best for Omega 3. You can read more about this on HealthyPlace.com. One patient I worked with noted that his mood greatly stabilized, and he became less paranoid, after eating a bunch of catfish. I had been thinking about suggesting Omega 3 to him, but after I learned that fact, it clenched it for me. He got on Omega 3, and an exercise and eating pattern designed to help him gain weight and muscular bulk.
Exercise is also an important factor in mood. Primarily in lifting mood. Patients often find that they develop more energy, appetite, and motivation with exercise. The most important thing is to learn from your own patterns. When you notice a change in your mood, think back about what you have stopped doing. It might be that you were more social, exercised, or made a change in your diet. If you figure out what changed was made, start doing those things again. With each episode, you can learn a little more about yourself. You can work on reducing the duration and intesity of your episodes. Over time, you will develop increased control over your mood, because of what you have learned.
When I worked at a mental health center, I often found myself scratching my head as to the diagnosis that was given to a patient by a psychiatrist. I had diagnosed one individual with an Adustment Disorder, which is anxiety and depressed mood related to a difficult situation in life. The psychiatrist diagnosed, schizoprenia, paranoid type. I was left utterly scratching my head as to why the psychiatrist had diagnosed schizophrenia, whereas I diagnosed an adjustment disorder. After looking at the medications that were prescribed, I found the reason, Abilify….an antipsychotic medication. Even though this patient did not meet the diagnostic criteria for Major Depression, let alone schizophrenia, the psychiatrist wanted to try Abilify; therefore diagnosed schizophrenia. That was the only conclusion I could come to. I saw this on numerous occasions. The diagnosis didn’t fit, and the medication was an antipsychotic. So, the diagnosis would be Bipolar Disorder, or a psychotic disorder.
As the Last Psychiatrist noted:
“You might argue the diagnosis leads us to the treatment, but in most cases, meds are used across all diagnoses, and more often than not a diagnosis is created to justify the medication.”
I had one patient, who for 14 years, was diagnosed with depressive disorder, NOS and personality disorder, NOS, until the psychiatrist wanted to try an antipsychotic. Suddenly, the diagnosis became schizoaffective disorder.
You may think that the diagnosis doesn’t have implications for treatment, but it does. If you are psychotic, you are not responsible for your behavior. The patient diagnosed as schizoaffective, was seen as psychotic by his wife and his psychiatrist. Therefore, he was not responsible for his Borderline, manipulative, aggressive and passive aggressive behaviors. This was the way the psychiatrist and his wife saw his behavior. I did not see the behavior this way because I was his psychologist. So, this puts me in a difficult position. I see him as responsible for the choices he makes, but the psychiatrist and wife see him as “mentally ill” when he engages in unsual behavior. I have to set limits and tell him that I would “find him a therapist who expects less” of him when the psychiatrist and husband justifies his behavior.
You see, I also do evaluations related to “sanity” and “fitness to stand trial.” This particular individual would likely be seen as incompetent and insane for his inappropriate behavior by the psychiatrist, but would be seen as perfectly sane by me who sees him as having a different diagnosis. You can say the diagnosis has no implications, but it really does in terms of personal responsibility and therapeutic issues with respect to psychotherapy.
So, this is one reason that I see diagnostic accuracy as being an important issue for treatment. My personality testing, interviews, and observations yield a diagnosis of a primary personality disorder, whereas, the psychiatrist’s desire to prescribe an antipsychotic yields a diagnosis of a psychotic disorder. So, it comes down to a situation where the patient has to decide to believe a professional who believes that they have control over their decisions versus a professional who believes they have no control or responsibility for their decisions. So far, when faced with this decision, my patients go with me, who believes that they have control and responsibility for their decisions. When they are legitimately psychotic, that’s one thing, when they are not, that is another. The diagnosis has real world implications in terms of personal responsibility and psychological treatment. Fortunately for most patients, when push comes to shove, they would rather believe that they are responsible for their behavior and have a desire to make efforts towards changing their maladaptive behavior. Unless they truly are psychotic….then the issue of personal responsibility has less meaning to them, because their reality contact is impaired.
So generally, when one of my patients is seeing a psychiatrist, the diagnosis has real world implications. And when they are not, the diagnosis has less meaning. Only the individual factors that contribute to the person’s difficulties are relevant. When the psychiatrist renders a diagnosis, then there are real world implications that affect the patient and their family.
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