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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
Believe it or not, we all have self-defeating expectations at times. What do I mean by this?
“I wish I could meet someone to date…”
“What have you done to try to meet somebody?”
“Well nothing. Nobody would want to date me anyway.”
“Hmmm…”
A self-defeating expectation is different from outright self-sabotage. With self-sabotage, a person approaches a goal only to shoot themselves in the foot by something they do. For example, a person might drop out of college with only a class or two left to complete before achieving a degree. Secretly, they may fear that they will fail in their chosen career path, so it’s short-circuited before it even has a chance to start.
Most often with both patterns, there is an element of anxiety that is often subtly concealed. There can sometimes be a deep-seated belief, “Whatever I do, I am doomed to fail.” This often becomes a self-fulfilling prophecy. A person brings about that which they fear.
Now, believe it or not, sometimes a self-defeating pattern brings about things that are more positive in a person’s life. I remember one lady whose grandmother wanted her to become a nurse. She had a very close relationship with her grandmother. One day, her grandmother was complaining about a pain in her leg. Her grandmother remarked, “Oh, I probably just pulled a muscle.” And she responded, “Yeah, probably so.” Two days later, the grandmother was dead because a blood clot in her leg dislodged and ended up in her heart. This woman felt tremendously guilty—that she had caused her grandmother’s death by not suggesting that she see a doctor. She felt she had to fulfill her grandmother’s dreams for her in becoming a nurse. But she struggled in college. She became more depressed. She kept flunking certain classes. It was not because she lacked intelligence—I tested her IQ level and she should have been able to get all A’s or at least A’s and B’s in every class she took. What we discovered was that she didn’t really want to be a nurse. Once she was able to resolve her feelings of guilt about her grandmother’s death, she was able to see that her grandmother would have wanted her to choose a profession that she wanted to choose. She switched majors and started getting the A’s and B’s that I knew she was capable of.
Sometimes the patterns of self-defeat run a little deeper and keep repeating over and over. Most often, this has to do with a pattern of experiences in childhood that leads the person to have deep doubts about the competence or effectiveness. These patterns take longer to resolve, because the self-defeating beliefs are very strong and resist change. Sometimes, these patterns take several years to resolve. There may be numerous subtle anxieties that keep a person in a repeating pattern of self-defeat. But, if you are truly motivated to overcome these patterns and have a shrink that you connect with, you can overcome these patterns with a lot of hard work. Unfortunately, there is no medication that will help you do this, and there is no quick fix. It is difficult to resolve these patterns outside of a psychotherapeutic relationship, because everyone has their blinders.
Race horses are fitted with blinders. The blinders restrict their field of vision to basically straight ahead of them. This is so they do not become frightened by other things that are going on around them. People have “mental blinders,” defenses that keep them from recognizing those things that frighten them. Psychotherapy can help people remove these blinders and confront their fears and anxieties.
This is a long overdue summary of recent psychology news items that I have found to be of interest.
Estrogen Relieves Psychotic Symptoms in Women With Schizophrenia – In a single double-blind study of the use of estrogen in women with severe schizophrenia, it was found that symptoms were significantly reduced compared to placebo. This study was related to the observation that many women with schizophrenia experience a relapse of psychotic symptoms or increased psychosis during low-estrogen phases of the menstrual cycle. This is interesting in that I have seen at least one patient who experienced psychosis ONLY during this phase.
Experimental Agent Safe, May “Dissolve” Amyloid Plaques in Mild to Moderate AD – If you have a parent, grandparent, or another relative with presumed Alzheimer’s disease, you probably know something about how devastating it can be. One theory of Alzheimer’s disease involves the notion of a build up of beta amyloid plaques in the brain. Apparently, this studied demonstrated the ability of an antibody to attack these plaques. While interesting, the researchers have yet to demonstrate that this actually improves cognition and memory. They hope this has to do with the short duration of the study, which was basically to test the safety of the drug.
Early Study Finds Increased Non-Hodgkin’s Lymphoma in Long-Term Users of Tricyclic Antidepressants – A recently published study showed an association between lymphoma and use of tricyclic antidepressant medication. The authors were careful to point out, that this was just an association, and there was no proof that the medications caused lymphoma. Tricyclic medications are an older generation of medication than the current SSRI medications. They are sometimes used when there is no response to SSRIs, and sometimes can be used as a sleep aid (trazadone specifically). The risk was higher with long-term use.
Sage Oil Supplements May Help Short-Term Memory – Short-term memory is commonly used to what’s referred to as recent memory. A study found that Sage oil supplements helped people have better recall on a word-learning task.
I’ve noted before that the role of psychiatrists is largely focused only the medication that a patient takes. To be fair, there are a few psychiatrists out there who do actual psychotherapy. Recent research shows this to be declining very steadily. (1)
I think the recent research on the decline of psychotherapy in psychiatry underestimates the ‘true’ shift in the field of psychiatry. The research is based on billing codes, and I know a little about that. I do computer consulting with a mental health center on their electronic medical record system. If the session goes over 15 minutes, it is billed as medication review + MD psychotherapy. So, in other words, if the session lasts more than 15 minutes, it is considered psychotherapy. This is whether it is true psychotherapy, or just an extended discussion of medication. There are no psychiatrists within a 50 mile radius of my practice that I would consider that provide true “psychotherapy.” So, the research results from 2004-2005 showing that 29% of psychiatrists provide ‘psychotherapy,’ is quite distorted. It frankly just means that sometimes they run over 15 minutes in the discussion of medication. I’m not saying that there are not any psychiatrists who provide psychotherapy, I’m just saying that it is very rare. That’s why you ought to be very skeptical about psychologists who have prescription privileges, because it is likely that they will go the way of psychiatrists.
(1). http://www.medscape.com/viewarticle/578684?src=mpnews&spon=12&uac=107497SN
There is one thing that is virtually guaranteed….if you go to a mental health center, you will probably see a psychiatrist for medication. In my private practice probably 10-15% of my patients take medication. When I worked at a mental health center, it was closer to 90-95%. What accounts for this vast difference?
1. In a mental health center, the assumption is that patients will be referred for medication. It is the basic assumption. There is also a financial insentive. Mental health centers get paid more for the services of psychiatrists than therapists or psychologists. Funding is ALWAYS a very important issue in mental health centers.
2. In private practice, most of the responsibility falls on me (instead of a system). I explain the options to my patients, that they may be interested to try medication, but as long as the problems do not represent a serious risk (loss of job, harm to self, ect…), medications may not be warranted. Although it is a very individual decision. So far, every patient I have seen that comes to me first without being on medication, does not start on medication. The majority of those who are intially on medication are able to get off of the medication eventually.
3. Expectations… All shrinks are human beings. They have different expectations of their patients. They have different expectations about what is possible with psychotherapy. They have different levels of knowledge. They have different levels of comfort. They have different views of human nature. These factors are critically important in how psychotherapy unfolds with a patient.
4. What seems to be much more important than diagnosis is a willingness on the part of the patient to keep coming in to treatment, to think about what is discussed in session between sessions, and to have a genuine motivation to make changes. Now, certain diagnoses sometimes make these things less likely (severe schizophrenia, severe bipolar disorder, or severe personality disorders for example). However, if these things are present (the positive factors), the diagnosis is much less significant.
5. Psychiatrists often “diagnose for the medication.” The FDA approves drugs for specific diagnoses. Nobody likes to be sued. So, psychiatrists often bend or distort the diagnosis in order to justify the medication they want to try. See my previous post, Diagnosing for the Medication.
So, while the desired medication is more important than symptoms at times for psychiatrists, for some therapists and psychologists, what is more important is a willingness to seriously consider what is talked about in-session, a willingness to follow through with recommendations, and a willingness to believe that psychotherapy may be helpful. To a great extent, the actual symptoms a person has are less important than these factors.
Now, I’ve seen some folks with the most rigid belief systems (such as blantant paranoia and fantasies of revenge), that are only addressable on a spritual basis. Absolutely nothing else works at all–believe me, I’ve tried. But, when they consider their thoughts in the context of their belief in God, they are willing to acknowledge the distortion and errors in their thinking. There are times when a person’s difficulties can be addressed in nothing other than a spiritual realm.
Recently, many psychologists, psychiatrists, the general public, and the media have been becoming more aware of bias in pharmaceutical research. The most recent work found that researchers design the study in order to favor the medication that is sponsored by the funding source. In this post, I will talk about some of the problems with pharmaceutical study research design.
The Placebo Washout Phase
Nearly all studies of pharmaceuticals, at least psychotropics, include an initial phase in which people who respond (read benefit) from a sugar pill are excluded from the study. So, if in the initial phase, they get better on placebo, they are excluded from the study. Purportedly, this is to remove an unimportant variable. But what this does is amplify the effects of the medication in the actual study. So, the drugs end up looking like they have a greater effect than they actually have. You end up with a group of folks who purportedly do not respond well to placebo taking an active drug versus a sugar pill. If you are going to run this type of study, the results need to state, “For people who are poor responders to placebo, the drug proved to be moderately efficacious.” That would be a more honest way to present the results, but I have never seen this occur. The exclusion of ‘placebo responders’ amplifies the effect of the ‘drug.’
Use of Percentages in Results
I have seen a number of popular drugs tested against placebo and the only statistics you find in the article to be “percent who achieved remission.” You read the whole article and the only thing presented is percentages and statistics to tell you if the percentages who fall into certain groups differ. This is also done so that the drug looks better than placebo. As an example, please see my previous analysis of on a study of antidepressants (Prozac) in children.
The Double Blind is not Blind
The double-blind research design is considered to be the ‘gold standard’ in pharmaceutical research. It is purported to be the most objective and best way of determining whether or not a drug has efficacy. The double-blind experiment is accurately described on Wikipedia:
Double-blind describes an especially stringent way of conducting an experiment, usually on human subjects, in an attempt to eliminate subjective bias on the part of both experimental subjects and the experimenters. In most cases, double-blind experiments are held to achieve a higher standard of scientific rigour.
So, the assumption is that the researchers do not know which group the study participants have been assigned, and the participants do not know which group they have been assigned to. Ah….but there’s a problem here. Previous research with antidepressant medication, reveals that both patients and doctors are pretty good at figuring out which group they are in, most likely because of side effects.
Some Solutions to the Problem
If you are reading pharmaceutical research that does not include a check to see if the blinding actually worked (in other words ask the researchers or physicians what group they think the participant is in and ask the participant what group they think they are in), uses a placebo washout phase, and only uses percentages or stats to tell if the percentages differ, be very skeptical of this research. Irving Kirsch has proposed a model for research that includes an ‘active placebo,’ in other words a drug that produces side effects, but in theory does not act in the same way as the drug. This should help to actually insure the ‘blind’ of the study. Finally, when research is funded by a pharmaceutical company, you need to be very skeptical of the results. If researchers are going to receive pharmaceutical industry funding, they need to be blind to the ‘who’ is funding them.
From time to time I plan to post summaries of recent interesting news in the fields of psychology and psychiatry. This is the first installment. I also provide my perspective, opinions, and observations.
Neonates in Intensive Care Endure Painful Procedures, Mostly Without Analgesia- A recent study found that infants in neo-natal intensive care experienced an average of 16 painful or stressful procedures per day. And that 79% of these were without analgesia. Very slowly, more practitioners are becoming aware of the long term consequences for traumatic experiences as an infant including the birth process. Unfortunately, the quackery of the ‘re-birthing’ movement has caused many practitioners to develop excessive cynicism to these notions. Even though people have no conscious memory of these experiences, there are unconscious memories that result in a number of problems in later life as a result of early traumatic experiences. I’ll write more on my clinical observations of early traumas in the future.
Childhood Nutrition Linked to Adult Intellectual Function- Okay, you’re a parent. You are not your child’s friend. Many parent’s nowadays are confused about their role. They want to be ‘friends’ with their child. That is not the role of a parent. The role of a parent is to educate a child, love a child, and nurture a child’s soul in the ways of the Lord so that they will be prepared for life’s challenges. So the kid says, “Yuck!!! I don’t want to eat it.” Show and explain that “big people,” adults, love to eat fruits and vegetables because ‘they make you smarter and stronger.’ As a child, I came to identify with my grandfather, who LOVED the fruit and vegetables that were grown in his garden. I think that nutritional changes are a key component of mental health. This must always be addressed in treatment. If you address this early on in a child’s life, you give them intellectual, and maturity advantages throughout their lives. Please do so. Fast food, such as McDonalds, Burger King, etc… are out of the question. But, please, do not take the easiest path with regard to parenting. You may think you are doing your child a favor, but you are not!
Relaxation Training for Anxiety: A Ten-Years Systematic Review With Meta-Analysis - The notion is that you ‘cannot be anxious and relaxed at the same time.’ For many people, relaxation techniques are very effective in helping you cope with anxiety and stress. For others, it is not effective at all. There is some evidence that meditation is more effective than relaxation as this article notes. Relaxation training is very different from activities that you may find relaxing. It is much deeper than that. But for some, relaxing is also seen as a threat. Psychotherapy with a competent psychotherapist can help you uncover why relaxation is so scary to you.. It may be a medical experience, “Just relax, this will be over in a minute.” And the word relax becomes associated with pain. There are many other variations on why people have trouble relaxing. If you have trouble learning relaxation techniques, you may require long-term psychotherapy to help resolve unconscious aspects that lead to your inability to relax.
Early Treatment of Migraine With Combination Therapy Effective, Well Tolerated- Headaches are a complex phenomena. This research shows that medication is very helpful compared to placebo. However, in my practice, it is very important to address the psychological factors of headaches. I remember one fellow who developed intense and severe ‘migraine headaches.’ This was described as a stabbing sensation that started in the back of the head. As a result, he would fall down on to the floor ’sobbing’ as a result. In analysis, it was uncovered that the location of the pain was exactly the same as when his father, ‘beat my head against the wall.’ After his head was beat against the wall, he fell to the floor sobbing. Now, sometimes headaches are a result of constipation or poor nutrition. You need to drink water ONLY, and stay away from soft drinks. It doesn’t matter if they are diet or otherwise. Diet soft drinks are somewhat worse actually. If you need caffeine, get it from coffee or tea. Eat high fiber cereal for breakfast, bananas, and orange juice for breakfast (every day). The article doesn’t say these things obviously, but these are things I have found to be very effective with my patients.
Wine Is Healthy In A New (Or Old) Way – The Last Psychiatrist has an interesting article on how wine consumption effects digestion. I’ve always thought that the combination of food and drink was very important in the health effects of what was being consumed. This article provides more evidence along those lines.
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.
It could have been titled that way. I think that would have been more provacative. But hey….
Researchers report finding:
“Striking similarities between the brains of gay men and straight women have been discovered by neuroscientists, offering fresh evidence that sexual orientation is hardwired into our neural circuitry.”
Maybe they should do a scan of heterosexual male genitalia and lesbian genitalia and see if that also matches. Or the hormone output of gay testes and heterosexual female ovaries. Perhaps on average the gay male left testicle is bigger than the right and the heterosexual female left ovary is bigger. But that would be what…..ridiculous?? But not with the brain right…….Right..
I think some gay men would be frankly offended by being told they have a female brain and some lesbians offended by being told they have a male brain.
But alas…you can read for yourself at the Guardian. And make up your own mind, whether you are female (or gay) or male (or lesbian)…
According to the article, when you ask for directions to get somewhere, you ought to be sure that the person you are asking is either a heterosexual male or a lesbian. If you ask for directions from someone who is gay or heterosexual female, you might get lost…..so ask that first before asking directions…
Recent research shows that antipsychotic medication is no more effective than placebo in reducing aggression in individuals with an intellectual disability. This type of medication is often prescribed for individuals with mental retardation, but the data now show that this type of intervention is no more effective than placebo. It should be noted that all interventions reduced symptoms, but placebo was the most effective. People should be amazed at the power of their own minds and expectations in producing changes even with intellectually disabled individuals. Intellectually disabled individuals seem to show some of the most impressive treatment gains in psychotherapy (this based on my experience). It seems likely that they are more accustomed to following directives than individuals without an intellectual disability, and are thus, less defensive. One of the most wise individuals I have ever worked with had an IQ of 66 (mild mental retardation). IQ does not mean that an individual possesses wisdom no matter what the IQ level is.
On internship, I remember one of my favorite supervisors saying to me, “I just want you to remember that when you are in private practice, that the standard of care for depression includes having the patients on an SSRI medication. It could open you to liability if a patient kills themselves.” I responded to him by saying that the research seems to indicate that by taking antidepressant medication, you may increase your risk of suicide, so you may be opening yourself up to liability by having the patient start an antidepressant medication. He seemed to understand my position, but noted that it is the general “standard of care.”
Over at PsychCentral, John Grohol, PsyD, presents new evidence that the pharmaceutical industry conducted questionnable statistical analyses that minimized the affect of Paxil in increasing suicide. I’m not saying Paxil directly causes suicide, because that is an individual decision. But it may increase other factors, such as agitation, which may increase the risk. I’m saying that psychologists and therapists who are comfortable in treating depression need not fear “increased risk of liability” for treating patients who are depressed without referring them for medication. It is a good idea to refer them to rule out physiological bases for their depression (such as hypothyroidism), but frankly there is no evidence at all that you would be increasing their suicide risk if they did not take medication for depression. Quite the opposite in my opinion.
Suicide is one of the most terrible and horribly damaging things that a person can do to friends and family. Many family members live with guilt, regret, and sadness for the rest of their lives. By comitting suicide you increase the risk that someone else in your family will do the same. You may be depressed and feel there are no other options. But there are always other options. I have seen patients who thought they had no other options completely turn their lives around and later think that they could never concieve of thinking about suicide again. If you consider suicide, get some help and know that you will not always feel the same way you do now. Emotions are temporary, and don’t last forever. Even though depression may last for a significant period of time, it will end. And with help it can end sooner.
I’ve seen yet another one. A child labeled as ADHD and put on 5 different medications (an antipsychotic, a stimulant, an antidepressant, a mood stabilizer, and 
clonidine–an antihypertensive). If I saw this every once in awhile, I could dismiss it more readily. But this practice seems to be becoming common based on the number of children I’ve seen with this type of polypharmacy.
Polypharmacy has multiple definitions. “Mixing many drugs in on prescription.” “The practice of prescribing multiple drugs to patients suffering from more than one malady.” “The prescription or dispensation of unnecessarily numerous or complex medicines.” This according to the freedictionary.com.
http://glennsacks.com/blog/?p=940
I’m not a psychiatrist. I’m a psychologist. For those of you who don’t know, psychologists can’t prescribe medication in most states. Psychiatrists can in all states. So, my viewpoint may be a bit biased. You see, I try to help people overcome problems without medication whenever possible. I’ve been able to keep several children off of medication for “ADHD.” So far, the only children on medication for ADHD that I see, are the ones who were already on medication when they came in. I’ve had to convince teachers and principals to be patient. I’ve had to give suggestions of how to deal with different children in the classroom. I’m sure there are some teachers who don’t like me very much because I don’t advocate medication in most cases. That’s tough luck as far as I am concerned. There are difficult adults and difficult children in the world. You deal with them the best that you can. Worst case scenario, you try some medication. But to me, that is the worst case scenario. Try everything else first.
Try nutritional changes, try exercise, try everything you can think of. If the child is failing then consider medication. Otherwise, use your brain, use the Internet, talk to others, and do anything you can to keep kids off of medication. Medication is warranted when there are severe consequences that may occur without it. The case I described at the beginning on this post, was given all of those medications because, “he gets a little irritable somethimes.” I feel sorry for this poor kid’s brain and mind. But he is not alone.
Some day, this whole approach of polypharmacy, the idea that you might as well throw every class of drug at a kid and maybe one will work, will be seen as in the perspective of psychosurgery (read labotomy) and electroconvulsive therapy for all kinds of problems.
New speculative research points out potential benefits of exercise on addiction. What do you think?
I think it is certainly worth a try. I’ll be trying it with some of my addicted patients. There is also a tidbit about exercise helping children with verbal and math skills. I use this already to help children and adults improve attention/concentration. It’s also certainly helpful with depression and anxiety. So, it doesn’t seem unreasonable to me that it might help with addiction.
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.
And the studies just keep coming. This time with Paxil showing that it was no better than placebo in adolescents, plus a relative increase in adverse events compared to placebo.
John Grohol, PsyD has a writeup on PsychCentral.
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