Psychiatry...

[ohioguy]

I went in with an open mind into this class (bear in mind I'm only about to finish MS1) but the course has been pushing me away from pursuing the specialty.


ADHD...at least in part medicalizing a normal part of childhood. More boys than girls have it? Maybe it's because boys are more hyperactive.

Homosexuality was taken out of the DSM largely because of political pressure...makes the entire DSM seem superficial.

One of our lecturers made a case that perhaps racism should be considered a disorder...well then most everyone back in the day would have been labeled with a disorder...way too socially constructed.

About 10% of Americans are on anti-depressant meds. Whatever happened to toughing it up and going with the ebbs and flows of life?

Of course pharmacotherapy has a place and has helped many people but as it's set up now psychiatry (and a lot of medicine) seems to over-medicate and create syndromes and disorders where none exist.

Anyone else? I'm sure I'm not the only one.

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[NickNaylor]

1) You don't seem to understand the difference between ADHD and variants of normal.

2) I'm not sure how this makes the entire DSM invalid. There's no doubt that the production of the DSM is a politically motivated process. A lot of $$$ is riding on the ability of certain unusual/abnormal traits to be classified as a "disorder."

3) I'm not sure how thoughts or opinions are a mental disorder, but ok. That's pretty disappointing if a practicing psychiatrist made that statement. It shows a complete lack of understanding of mental illness.

4) Ebbs and flows of life? Lol, ok. Again, failing to understand the difference between a bone fide disorder and variants of normal.

5) The fact that mental illness is more difficult to define and characterize does not mean that it is not worth treating. You're right in that psychopharmacology leaves much to be desired. Let me know what you think about that, though, after you've seen someone who is fully psychotic make a complete 180 after being treated with antipsychotics.

Troll harder brah.

 

[DermViser]

"Whatever happened to toughing it up and going with the ebbs and flows of life?"

You're correct, Psychiatry is not the specialty for you. Move on.

 

[EMDO2018]

Don't be THAT guy

I went in with an open mind into this class (bear in mind I'm only about to finish MS1) but the course has been pushing me away from pursuing the specialty.


ADHD...at least in part medicalizing a normal part of childhood. More boys than girls have it? Maybe it's because boys are more hyperactive.

Homosexuality was taken out of the DSM largely because of political pressure...makes the entire DSM seem superficial.

One of our lecturers made a case that perhaps racism should be considered a disorder...well then most everyone back in the day would have been labeled with a disorder...way too socially constructed.

About 10% of Americans are on anti-depressant meds. Whatever happened to toughing it up and going with the ebbs and flows of life?

Of course pharmacotherapy has a place and has helped many people but as it's set up now psychiatry (and a lot of medicine) seems to over-medicate and create syndromes and disorders where none exist.

Anyone else? I'm sure I'm not the only one.

 

[Anastomoses]

Sure, that's one perspective. Too complicated for my pay grade. But no, I don't share your views. I believe very strongly in genetics being highly imperfect and that in many cases may need a little help. Hand in hand with this belief is that homosexuality is most likely founded in genes - and the way psychiatry is studied today is that if something is not disruptive or harmful, then it is not a disease.

 

[BurghStudent]

Has anyone read The Myth of Mental Illness by Thomas Szasz, a psychiatrist? Not subscribing to his ideas, but it is an interesting read. You can find the essay online.

 

[Wordead]

I'll probably be one of the few that is more on your side than not. A lot of mental conditions are way over-diagnosed and meds are just thrown at people.

And yes, the DSM is ridiculous because it is essentially consensus opinion with no real evidence to back it up. There is no testing to be done for most conditions - it is essentially 100% the opinion of the psychiatrist, and whether a patient responds to a trial of medication.

1) You don't seem to understand the difference between ADHD and variants of normal.

4) Ebbs and flows of life? Lol, ok. Again, failing to understand the difference between a bone fide disorder and variants of normal.

5) The fact that mental illness is more difficult to define and characterize does not mean that it is not worth treating. You're right in that psychopharmacology leaves much to be desired. Let me know what you think about that, though, after you've seen someone who is fully psychotic make a complete 180 after being treated with antipsychotics.

I disagree that it is as clear as you seem to imply. There are definitely the extremes where a person has obvious MDD/ADHD/Bipolar/whatever, or is having an active psychotic break, but definitely I have seen (and you, I'm sure) cases where people were diagnosed and treated in that gray area in between. Did they truly need it? Maybe, maybe not. But the psychiatrist is always going to lean towards treatment. And these diagnoses are lifelong. I'm sure you've seen patients during your rotation where you take their history and just go - this doesn't sound anything like your diagnosed condition.

 

[Frazier]

I went in with an open mind into this class (bear in mind I'm only about to finish MS1) but the course has been pushing me away from pursuing the specialty.

ADHD...at least in part medicalizing a normal part of childhood. More boys than girls have it? Maybe it's because boys are more hyperactive.

Homosexuality was taken out of the DSM largely because of political pressure...makes the entire DSM seem superficial.

One of our lecturers made a case that perhaps racism should be considered a disorder...well then most everyone back in the day would have been labeled with a disorder...way too socially constructed.

About 10% of Americans are on anti-depressant meds. Whatever happened to toughing it up and going with the ebbs and flows of life?

Of course pharmacotherapy has a place and has helped many people but as it's set up now psychiatry (and a lot of medicine) seems to over-medicate and create syndromes and disorders where none exist.

Anyone else? I'm sure I'm not the only one.

We are just finishing up Psych at my school as well.

It was/is awesome. Best course of first year. Pretty damn relieving to finally have a course with material that isn't painful (or at best, tolerable) -- but instead enjoyable -- to study at length.

Apparently it's the "different strokes, different folks" thing at play... Which is great really, because the kind of person that really enjoys biochemistry (random example of cut/dry hard sci) might not enjoy something like psych...and vice versa.

My professor also made a note about racism, it makes me wonder if we go to the same school -- or if it is a common topic for psych professors to pontificate about during lecture. At least in my professor's defense, he did not claim that it was a disorder (nor tried to seriosuly convince us) -- rather it was a game of devil's advocate: "here is the criteria of how we determine who has disorder XYZ", "look, I can make racism fit that mold", "what do you think? yay or nay?"

In regards to politics (e.g. homosexuality no longer being a d/o), it might be a touch of that and a touch of the fact that many of the disorders are measured against what is "normal" by society. So for example, the public does not accept psychosis as a "normal" state of mind for people to go about their day in, the public does not accept purging as a "normal" ritual after meals, the public does not accept not being able to sleep as "normal".

Half a century ago, society did not accept homosexuality as a normal thing. Today, by and large, society accepts it as "normal". It makes sense then for the medical community to no longer consider it a disorder (something defined as: "a derangement or abnormality of function").

I think you mention "socially constructed" in your post. I imagine you would agree that the above example would have society playing a large role in constructing that DSM change.

That's how it goes though. Psych is basically the most person-focused specialty in medicine to begin with (disclaimer: personal opinion). Pretty much every other specialty has a good amount of lab values to fall back on or measure [or images to examine] in order to arrive/confirm a diagnosis. Comparatively, in psych, it starts with the patient and ends with the patient.

EDIT: In retrospect "most person-focused" sounds a bit emotionally charged and insinuates that perhaps other specialties don't care about the person. Def not saying that.

 

[Evil_Abed]

Psych is basically the most person-focused specialty in medicine to begin with. Pretty much every other specialty has a good amount of lab values to measure, images to examine in order to arrive/confirm a diagnosis. In psych, it starts with the patient and ends with the patient.

While I agree with most of what everyone's saying, that is not even remotely true. No. Every field can be the most person-focused specialty in medicine. It comes down to the individual physician providing care. I've seen some surgeons be more person-focused than some psychiatrists and vice versa.

Also, you order quite a lot of lab tests in psych to rule out medical causes of the illness. For example, the work-up for a first episode of psychosis is pretty lengthy (including TSH, free T4, RPR, B12, folate, vitamin D, EEG, MRI brain, CBC, CMP, ANA w/reflex, RF, HIV, etc) -- maybe that's just my institution, but that's the "standard" lab order for first-onset psychosis and I'm not even including the complete list. You gotta rule out a treatable medical illness before saying that it's psychiatric.

 

[StIGMA]

Psychiatric disease prevalence changes dramatically depending on disease definition (which is influenced by multifactorial causes including financial stakeholders/whether treatment exists/politics/current state of research). However, psychiatric disease prevalence also changes due to environmental causes, just like other illnesses (eg: poor diet/exercise>HTN/obesity>heart disease in the US), as our bodies weren't designed with the modern technology-driven, constantly stressed, intensely self-seeking/promoting, advertisement-driven, 'keep up with the Joneses' lifestyle in mind.

If you want to help people cope with mental illness, psychiatry is a great field. Just because you (and I) have the 'tough it out' mentality doesn't mean anyone else is weaker. I'm sure we both know many people who 'tough out' medical issues by never seeing their doctor, too.

 

[Frazier]

While I agree with most of what everyone's saying, that is not even remotely true. No. Every field can be the most person-focused specialty in medicine. It comes down to the individual physician providing care. I've seen some surgeons be more person-focused than some psychiatrists and vice versa.

Also, you order quite a lot of lab tests in psych to rule out medical causes of the illness. For example, the work-up for a first episode of psychosis is pretty lengthy (including TSH, free T4, RPR, B12, folate, vitamin D, EEG, MRI brain, CBC, CMP, ANA w/reflex, RF, HIV, etc) -- maybe that's just my institution, but that's the "standard" lab order for first-onset psychosis and I'm not even including the complete list. You gotta rule out a treatable medical illness before saying that it's psychiatric.

Yeah, that's true. I should have been more clear.

I was referencing the common complaint among my peers that the diagnosis criteria is too "subjective" and that there is nothing as straightforward as "give me a urine sample and I will tell you if you have diabetes" or "let me take your BP and I'll tell you if you have HTN".

However, I still would say there are inherent differences in the diagnosis approach to arriving at a dx via ruling out alternatives (your example) VERSUS "here is film of your shattered femur... you have a break".

For the first part that you disagreed with, that's perfectly fine. Different opinions are a good thing. However, my definition of the word - "most" - kind of conflicts with your claim that "every single specialty can be the most person-focused specialty in medicine".

 

[Evil_Abed]

However, I still would say there are inherent differences in the diagnosis approach to arriving at a dx via r/o alternatives VERSUS here is film of your shattered femur... you have a break.

It's pretty common across fields, in my experience. If a young guy comes in to the ER with chest pain, it's pretty unlikely that he's having an MI. That's still something I want to rule-out and I would always have to keep in mind other "danger diagnoses" in my head (ex. PE) and rule them out, whether it's through my H&P or with labs/imaging, before saying "yea, that's just MSK pain and you should be fine." Even if someone comes in with an obviously broken femur, you have to rule out a bunch of things (ex. is this leg neurovascularly intact, is there risk of compartment syndrome, is there bleeding into the thighs, etc).

I haven't noticed a significant change in mindset on how to approach psychiatric patients vs. non-psychiatric patients on my rotations so far. The same principles apply, for the most part.

 

[Frazier]

It's pretty common across fields, in my experience. If a young guy comes in to the ER with chest pain, it's pretty unlikely that he's having an MI. That's still something I want to rule-out and I would always have to keep in mind other "danger diagnoses" in my head (ex. PE) and rule them out, whether it's through my H&P or with labs/imaging, before saying "yea, that's just MSK pain and you should be fine." Even if someone comes in with an obviously broken femur, you have to rule out a bunch of things (ex. is this leg neurovascularly intact, is there risk of compartment syndrome, is there bleeding into the thighs, etc).

I haven't noticed a significant change in mindset on how to approach psychiatric patients vs. non-psychiatric patients on my rotations so far. The same principles apply, for the most part.

All credited, but partly only tangentially-related, IMO. You mention that ruling out is common in other specialties. However, we are talking bread and butter here. I don't know if any other specialty has such a heavy reliance on [(patient reporting + ruling out) - (direct diagnosis via lab work or imaging)].

 

[Nasrudin]

This is not a loaded rhetorical device but a sincere question:

A family physician starts a diabetic on metformin, he is not throwing anything at anyone. A cardiologist ups the dosage on a statin, and she is not slinging a pharmaceutical with suspect motives.

And yet a psychiatrist approaches a clinical problem with drug therapy and it's throwing something at someone. Dubiously.

Why?

In full disclosure, I am fully cognizant of many of the problems psychiatry faces as a field. We are clearly at an infantile stage of development compared to other areas of medicine. Our understanding of mental illness is very limited.

But what I want from my colleagues in other fields is to be educated and sophisticated critics of psychiatry. What I see by vast majority are hackneyed regurgitations of criticism that exist in popular culture at large. Automated. Not well thought out. Witless and wanton. And if I may say so to the detriment of our patients.

 

[Evil_Abed]

I don't know if any other specialty has such a heavy reliance on (patient reporting + ruling out) - (direct diagnosis via lab work or imaging).

What year are you? Not trying to be condescending; genuinely curious. Because none of the clerkships I've rotated through this year have disregarded or de-emphasized patient reporting and ruling out of serious illnesses. Both are a very important part of generating a differential diagnosis. Not only that, the number of labs and images I've reviewed on my psych rotation has been pretty on par with other rotations -- maybe slightly less, but not significantly so.

 

[Frazier]

What year are you? Not trying to be condescending; genuinely curious. Because none of the clerkships I've rotated through this year have disregarded or de-emphasized patient reporting and ruling out of serious illnesses. Both are a very important part of generating a differential diagnosis. Not only that, the number of labs and images I've reviewed on my psych rotation has been pretty on par with other rotations -- maybe slightly less, but not significantly so.

MS1. I admit you clearly are further along the journey than I am, so I should yield to some degree given the fact you have experienced more than I. (Nevertheless, I appreciate your willingness for some relaxed, late night debate).

Perhaps, my earlier post was still a bit convoluted. I am not saying that other specialties ignore ruling out illnesses, or that psychiatry never looks at films.

Rather, my claim is that the scales of psychiatry are heavier on the subjective/rule-out side for their bread and butter conditions and most (all?) other specialties are tipped toward the concrete dx (via ways of things like labwork/imaging) in comparison for their bread and butter.

 

[StIGMA]

This is not a loaded rhetorical device but a sincere question:

A family physician starts a diabetic on metformin, he is not throwing anything at anyone. A cardiologist ups the dosage on a statin, and she is not slinging a pharmaceutical with suspect motives.

And yet a psychiatrist approaches a clinical problem with drug therapy and it's throwing something at someone. Dubiously.

Why?

In full disclosure, I am fully cognizant of many of the problems psychiatry faces as a field. We are clearly at an infantile stage of development compared to other areas of medicine. Our understanding of mental illness is very limited.

But what I want from my colleagues in other fields is to be educated and sophisticated critics of psychiatry. What I see by vast majority are hackneyed regurgitations of criticism that exist in popular culture at large. Automated. Not well thought out. Witless and wanton. And if I may say so to the detriment of our patients.

I have no strong negative opinion of psychiatry, but the worst (and genuine) critique is the diagnoses are so numerous and so broad that you could effectively classify everyone with a psychiatric diagnosis. Exclusion of psychiatric disease (eg: what is normal, how thorough is the attempt to rule out a diagnosis) does not seem to be the goal, as in many areas of medicine; rather, labeling with a diagnosis/disease appears to be the goal. In the same vein, many diagnoses are overly subjective.

 

[Nasrudin]

I have no strong negative opinion of psychiatry, but the worst (and genuine) critique is the diagnoses are so numerous and so broad that you could effectively classify everyone with a psychiatric diagnosis. Exclusion of psychiatric disease (eg: what is normal) does not seem to be the goal, as in many areas of medicine; rather, labeling with a diagnosis/disease appears to be the goal.

I agree. I appreciate that you see the process as inherent to medicine itself. But given the precarious nature of your namesake with our diagnoses, it does make psychiatric over diagnosis more egregious. Particularly when neurochemistry in manipulated without understanding it's consequence for brain development.

What most people don't realize is that child psychiatry gets the absolute trainwreck situations that have failed everything else and families and teachers and juvenile justice systems show up exasperated and desperate. Your pediatrician is the point person for psych meds dispensing. As are your family doctors.

 

[DermViser]

1) You don't seem to understand the difference between ADHD and variants of normal.

2) I'm not sure how this makes the entire DSM invalid. There's no doubt that the production of the DSM is a politically motivated process. A lot of $$$ is riding on the ability of certain unusual/abnormal traits to be classified as a "disorder."

3) I'm not sure how thoughts or opinions are a mental disorder, but ok. That's pretty disappointing if a practicing psychiatrist made that statement. It shows a complete lack of understanding of mental illness.

4) Ebbs and flows of life? Lol, ok. Again, failing to understand the difference between a bone fide disorder and variants of normal.

5) The fact that mental illness is more difficult to define and characterize does not mean that it is not worth treating. You're right in that psychopharmacology leaves much to be desired. Let me know what you think about that, though, after you've seen someone who is fully psychotic make a complete 180 after being treated with antipsychotics.

Troll harder brah.

If you aren't stenting, scoping, or sticking in other hardware, then apparently, you're not a "real doctor". What a fool.

 

[Wordead]

This is not a loaded rhetorical device but a sincere question:

A family physician starts a diabetic on metformin, he is not throwing anything at anyone. A cardiologist ups the dosage on a statin, and she is not slinging a pharmaceutical with suspect motives.

And yet a psychiatrist approaches a clinical problem with drug therapy and it's throwing something at someone. Dubiously.

Why?

In full disclosure, I am fully cognizant of many of the problems psychiatry faces as a field. We are clearly at an infantile stage of development compared to other areas of medicine. Our understanding of mental illness is very limited.

But what I want from my colleagues in other fields is to be educated and sophisticated critics of psychiatry. What I see by vast majority are hackneyed regurgitations of criticism that exist in popular culture at large. Automated. Not well thought out. Witless and wanton. And if I may say so to the detriment of our patients.

Fair point. As I used the phrase, I'll respond with my opinion.

1. Diagnoses - we all rotate through psych. We all see how random diagnoses can be - 5 psychiatrists, 5 diagnoses, 5 different treatments. If the attendings can't even agree on what a patient has, how are you supposed to agree on a course of action? What good is any "study" if you can't even be sure if the study population actually has the disease?

2. The mechanism and effects being known. We understand metformin, statins. They have clear, specific indications. Psych meds are relatively unknown, and are used for a million different psych diagnoses. And why do people respond to one SSRI and not another? There is no way to predict how a patient responds to an antipsychotic - or which is best for them. Did the medication actually help?

3. Whiny baby syndrome - yeah, I know the patients believe they have a problem. But a large proportion of them have problems that I personally say "so what? This is not even close to an actual problem. Grow up." Obviously I'm not talking about psychotics, more depression/adhd/anxiety. And a lot of them still receive medication. Do they actually need it? I would argue no for a lot of the patients I saw.

Would like to hear thoughts on those points.

 

[Frazier]

Fair point. As I used the phrase, I'll respond with my opinion.

1. Diagnoses - we all rotate through psych. We all see how random diagnoses can be - 5 psychiatrists, 5 diagnoses, 5 different treatments. If the attendings can't even agree on what a patient has, how are you supposed to agree on a course of action? What good is any "study" if you can't even be sure if the study population actually has the disease?

2. The mechanism and effects being known. We understand metformin, statins. They have clear, specific indications. Psych meds are relatively unknown, and are used for a million different psych diagnoses. And why do people respond to one SSRI and not another? There is no way to predict how a patient responds to an antipsychotic - or which is best for them. Did the medication actually help?

3. Whiny baby syndrome - yeah, I know the patients believe they have a problem. But a large proportion of them have problems that I personally say "so what? This is not even close to an actual problem. Grow up." Obviously I'm not talking about psychotics, more depression/adhd/anxiety. And a lot of them still receive medication. Do they actually need it? I would argue no for a lot of the patients I saw.

Would like to hear thoughts on those points.

That's a common complaint I've seen on the forums and the web in general. So I just wanted to throw this out there in a vacuum for any readers on the internet that think psych stands alone in regards to reliability:

Interestingly, there have been studies that compare the Interrater reliability in psych's bread & butter compared to other conditions...

For those rusty with stats, " Cohen's kappa was designed to estimate the degree of consensus between two judges after correcting for the amount of agreement that could be expected by chance alone."

Table 1.
PSYCHIATRIC DIAGNOSES KAPPAS FOR IN-PERSON INTERVIEWS
Major depression 0.73
Alcohol dependence 0.86
Bipolar disorder 0.76
Panic disorder 1.00
Average kappa = 0.83

MEDICAL/NEUROLOGICAL DIAGNOSES KAPPAS
Ischemic stroke 0.53 [average]
Colorectal adenocarcinoma 0.78
Renal stenosis 0.43
Knee osteroarthritis 0.1
Breast cancer (mammographic density measurements) 0.89
Average kappa = 0.55

More here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2860522/

 

[StIGMA]

Table 1.
PSYCHIATRIC DIAGNOSES KAPPAS FOR IN-PERSON INTERVIEWS
Major depression 0.73
Alcohol dependence 0.86
Bipolar disorder 0.76
Panic disorder 1.00
Average kappa = 0.83

MEDICAL/NEUROLOGICAL DIAGNOSES KAPPAS
Ischemic stroke 0.53 [average]
Colorectal adenocarcinoma 0.78
Renal stenosis 0.43
Knee osteroarthritis 0.1
Breast cancer (mammographic density measurements) 0.89
Average kappa = 0.55

More here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2860522/

This is such a poorly executed, biased study that it is meaningless. The medical/neurological data are of course biased/mis-stated (eg: the osteoarthritis study is primarily comparing radiograph vs joint inspection reliability, not clinical OA diagnosis), while the psychiatric diagnoses are looking at interobserver reliability between TWO interviewers (on diagnoses with clear criteria). Meaningless.

 

[Wordead]

That's a common complaint I've seen on the forums and the web in general. So I just wanted to throw this out there in a vacuum for any readers on the internet that think psych stands alone in regards to reliability:

Interestingly, there have been studies that compare the Interrater reliability in psych's bread & butter compared to other conditions...

For those rusty with stats, " Cohen's kappa was designed to estimate the degree of consensus between two judges after correcting for the amount of agreement that could be expected by chance alone."

Table 1.
PSYCHIATRIC DIAGNOSES KAPPAS FOR IN-PERSON INTERVIEWS
Major depression 0.73
Alcohol dependence 0.86
Bipolar disorder 0.76
Panic disorder 1.00
Average kappa = 0.83

MEDICAL/NEUROLOGICAL DIAGNOSES KAPPAS
Ischemic stroke 0.53 [average]
Colorectal adenocarcinoma 0.78
Renal stenosis 0.43
Knee osteroarthritis 0.1
Breast cancer (mammographic density measurements) 0.89
Average kappa = 0.55

More here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2860522/

I know I will be accused of disregarding research when offered to me, but come on this is a psychiatrist cherry picking specific studies to support his position. He admits it himself "These selective results, to be sure, represent only a few studies that I chose as demonstration cases. One can certainly find higher kappas for some medical or neurological disorders".

I mean, come on, these results are saying that there was a PERFECT consensus on a diagnosis of panic disorder, but basically absolutely nobody was able to reach consensus on a diagnosis of OA of the knee? Nobody else see a problem with these results?

 

[StIGMA]

I know I will be accused of disregarding research when offered to me, but come on this is a psychiatrist cherry picking specific studies to support his position. He admits it himself "These selective results, to be sure, represent only a few studies that I chose as demonstration cases. One can certainly find higher kappas for some medical or neurological disorders".

I mean, come on, these results are saying that there was a PERFECT consensus on a diagnosis of panic disorder, but basically absolutely nobody was able to reach consensus on a diagnosis of OA of the knee? Nobody else see a problem with these results?

For the psych... because they compared the results of two psychiatrists using a defined protocol given by the author (DSM-III-R). So two pre-selected psychiatrists read into the study design and given a structured protocol could not agree on pre-selected inpatients except for panic disorder (inpatients... so severe illness presumably... who could say "I am here for X" or "have a history of X" or take such and such meds...).

 

[Frazier]

This is such a poorly executed, biased study that it is meaningless. The medical/neurological data are of course biased/mis-stated, while the psychiatric diagnoses are looking at interobserver reliability between TWO interviewers (on diagnoses with clear criteria). Meaningless.

I'd like to hear more on mis-stating..

For example, the results of the Colorectal adenocarcinoma scores are taken directly from
"The reliability of routine pathologic diagnosis of colorectal adenocarcinoma".

Sure, things could be done better...all in one study, etc.

If that investigation exists already, I would love to see it.

 

[StIGMA]

I'd like to hear more on mis-stating..

For example, the results of the Colorectal adenocarcinoma scores are taken directly from
"The reliability of routine pathologic diagnosis of colorectal adenocarcinoma".

Sure, things could be done better...all in one study, etc.

If that investigation exists already, I would love to see it.

Point is the psych "data" from that paper is rubbish. It is a shame that the author holds a position at a medical school and publishes misleading, poorly designed studies like that.

 

[NickNaylor]

I'll probably be one of the few that is more on your side than not. A lot of mental conditions are way over-diagnosed and meds are just thrown at people.

And yes, the DSM is ridiculous because it is essentially consensus opinion with no real evidence to back it up. There is no testing to be done for most conditions - it is essentially 100% the opinion of the psychiatrist, and whether a patient responds to a trial of medication.



I disagree that it is as clear as you seem to imply. There are definitely the extremes where a person has obvious MDD/ADHD/Bipolar/whatever, or is having an active psychotic break, but definitely I have seen (and you, I'm sure) cases where people were diagnosed and treated in that gray area in between. Did they truly need it? Maybe, maybe not. But the psychiatrist is always going to lean towards treatment. And these diagnoses are lifelong. I'm sure you've seen patients during your rotation where you take their history and just go - this doesn't sound anything like your diagnosed condition.

Suffice to say I don't feel the need to get into the debate of defending psychiatry as a legitimate field. I'm disappointed that you - a colleague - approach psychiatry in this way and see the field as you do. I'm not sure if you had a ****ty rotation or clueless preceptors or what, but I simply can't relate to your experience. It's not that I completely disagree with all of your criticisms, but I'm simply not going to try and have a discussion with someone who says that the approach is that meds are "just thrown at people." If only we could just CT everyone and find the spot that doesn't belong, right? Then it'd be a real disease. Just about the only thing I'd agree with you about are personality disorders. Then, yes - I could completely see the "5 psychiatrists" anecdote coming true, and I would agree that treating those individuals is going down a path that may or may not help patients. But depression? Psychotic disorders? Anxiety disorders? Sorry, can't agree with you there.

I think it's interesting that trainees are willing to swallow hook, line, and sinker just about anything with respect to teaching when it comes to the diagnosis of disease in almost every other field but in psychiatry suddenly everyone becomes the armchair psychiatrist with an opinion on everything. Just because the diagnoses are "soft" and the disease process more subtle doesn't make the medicine any less legitimate. Interestingly enough, it's typically these same people who knock psychiatry yet are the first people to call a consult as soon as a patient becomes "unruly" - irrespective of whether an actual psychiatric process is going on. If only those damn people didn't get in the way of our MEDICINE!

Sent from my iPhone using Tapatalk

 

[Psai]

Yeah, that's true. I should have been more clear.

I was referencing the common complaint among my peers that the diagnosis criteria is too "subjective" and that there is nothing as straightforward as "give me a urine sample and I will tell you if you have diabetes" or "let me take your BP and I'll tell you if you have HTN".

However, I still would say there are inherent differences in the diagnosis approach to arriving at a dx via ruling out alternatives (your example) VERSUS "here is film of your shattered femur... you have a break".

For the first part that you disagreed with, that's perfectly fine. Different opinions are a good thing. However, my definition of the word - "most" - kind of conflicts with your claim that "every single specialty can be the most person-focused specialty in medicine".

A lot of diagnoses can be pretty subjective. You gather data, you interpret it and then you make a decision depending on what's the most likely cause. Oh Mrs. Jones, your bp has been around 139/89 I guess you're "pre-hypertensive". I mean sure, there are studies that show that the higher the bp is, the more likely you are to get things like atherosclerosis and ventricular remodeling but those numbers are not absolute, derived from principles of physics. Somebody took a bunch of measurements and came up with these guidelines for when a bp should be labeled this as opposed to that and they are very good but nothing in medicine is completely straightforward. There are a ton of things that can change your bp like getting up, being stressed, medications, etc. Even just going to the doctor's office can raise your bp.

 

[BobbyB]

the further along you go into medicine, the more you will learn that no specialty is black and white

treatment algorithms and laboratory cutoff values change a lot

 

[NickNaylor]

Fair point. As I used the phrase, I'll respond with my opinion.

1. Diagnoses - we all rotate through psych. We all see how random diagnoses can be - 5 psychiatrists, 5 diagnoses, 5 different treatments. If the attendings can't even agree on what a patient has, how are you supposed to agree on a course of action? What good is any "study" if you can't even be sure if the study population actually has the disease?

2. The mechanism and effects being known. We understand metformin, statins. They have clear, specific indications. Psych meds are relatively unknown, and are used for a million different psych diagnoses. And why do people respond to one SSRI and not another? There is no way to predict how a patient responds to an antipsychotic - or which is best for them. Did the medication actually help?

3. Whiny baby syndrome - yeah, I know the patients believe they have a problem. But a large proportion of them have problems that I personally say "so what? This is not even close to an actual problem. Grow up." Obviously I'm not talking about psychotics, more depression/adhd/anxiety. And a lot of them still receive medication. Do they actually need it? I would argue no for a lot of the patients I saw.

Would like to hear thoughts on those points.

1) Give some specific cases in which this was the case. I never saw this during my clerkship.

2) Why does this matter at all to anything? There are people who are unresponsive to a variety of drugs that are used routinely. There are drugs used in a variety of fields that have unclear or unknown mechanisms of action. Anesthesia is probably the best example here. We don't accuse anesthesiologists of vein charlatans though, do we? Very little of OB/GYN practice is evidence-based. Do you chastise them as strongly as you do psychiatrists? Also keep in mind that long term outcome data is lacking for a huge amount of drugs used in routine practice. In many cases interventions are done simply because they "seem right" but the data supporting their use is lacking. Look at "cutting-edge" surgical techniques and procedures for a prime example here. The reality is that much of what you complain about psych is equally applicable to other fields as well.

3) Who cares? If a patient feels better on medication and thinks the medication is worthwhile, is that meaningless? The fact that you question whether anxiety is even a disorder worth treating makes me not take you seriously. Now you're right that psychiatrists may misdiagnose and label someone with an anxiety disorder when that isn't the case, but if you've ever had a panic attack or dealt with anxiety before then I think you might be a tad offended at your own comments.

Your school either did you a great disservice on your psych rotation or you failed to approach it with an open mind. I mean, really, I'm surprised that your bringing up the complaints that you did. This is Tom Cruise level complaining here.


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[Nasrudin]

Fair point. As I used the phrase, I'll respond with my opinion.

1. Diagnoses - we all rotate through psych. We all see how random diagnoses can be - 5 psychiatrists, 5 diagnoses, 5 different treatments. If the attendings can't even agree on what a patient has, how are you supposed to agree on a course of action? What good is any "study" if you can't even be sure if the study population actually has the disease?

2. The mechanism and effects being known. We understand metformin, statins. They have clear, specific indications. Psych meds are relatively unknown, and are used for a million different psych diagnoses. And why do people respond to one SSRI and not another? There is no way to predict how a patient responds to an antipsychotic - or which is best for them. Did the medication actually help?

3. Whiny baby syndrome - yeah, I know the patients believe they have a problem. But a large proportion of them have problems that I personally say "so what? This is not even close to an actual problem. Grow up." Obviously I'm not talking about psychotics, more depression/adhd/anxiety. And a lot of them still receive medication. Do they actually need it? I would argue no for a lot of the patients I saw.

Would like to hear thoughts on those points.

1. Hyperbole reveals an unbalanced attack. You're reacting emotionally to psychiatry and psychiatric patients and looking for situations that justify those feelings. Differing opinions occur everywhere in medicine. Why should it surprise you that given all of psychiatric diagnoses are based on patient history that different clinicians elicited different histories and therefore different preliminary diagnoses. Especially in an inpatient setting, which what most medical students experience. We don't have biological markers or lab tests or radiologic findings or pathology reports. So of course we are fumbling through the subjective nature of consciousness itself.

You are correct, research is difficult when identifying your patient population is a subjective process.

2. Did the medication help indeed? That is where we are at in psychiatry. All of our mechanisms are theoretical. And we use the same medications for entirely different diagnoses. That should raise alarm bells in any rational mind. So basically our diagnostic manual is a statistical encyclopedia of patients with similar symptoms. It is researched with the best evidence and understanding we have. Which is entirely problematic in itself. As a human with a phenomenon we call consciousness, I blame you, me and any other bipedal ape for being in the ridiculous position of being aware of self enough to ask these questions for our inscrutability in answering them.

3. You've basically illustrated the problem of egocentrism. In attempting to understand and interpret the consciousness of another human being we are stuck with the tool of our own consciousness which we know best. It takes a certain kind of person to be able to reimagine the possibility of the patient's unique consciousness through their experience.

I'll give an example of my egocentrism. I've had multiple back surgeries after a work injury and was on heavy round the clock narcotics for 2 years. After my 2nd major surgery and my wound healed I told myself one day I'm not taking any more narcotics. Period. And I didn't. And went into violent withdrawal. I was curled up in the fetal moaning, waiting for it to pass.

So on my addiction psychiatry rotation I was having trouble empathizing with heroine addicts and why they seemed convinced they would die if they didn't get their suboxone.

I asked my seniors on the psych forum about my rejection of their experience. Learned from them. And after thinking about it decided I was stuck with the problem of viewing things through my own consciousness which had the resources and ability to go cold turkey. And that not everyone was me.

This is both the problem of the doctor/patient relationship in psychiatry and why it is so fascinating. It requires the commitment to imagining the consequences of alien consciousness to our own.

 

[Elisabeth Kate]

Fair point. As I used the phrase, I'll respond with my opinion.

1. Diagnoses - we all rotate through psych. We all see how random diagnoses can be - 5 psychiatrists, 5 diagnoses, 5 different treatments. If the attendings can't even agree on what a patient has, how are you supposed to agree on a course of action? What good is any "study" if you can't even be sure if the study population actually has the disease?

Would love to know where you did your psych rotation that your five attendings each gave a patient different diagnoses with different treatments. It's difficult to take your post seriously when make such claims because, as you said, we ALL rotate through psych and I have yet to hear of anyone experieincing what you say you experienced. Awaiting your example.

2. The mechanism and effects being known. We understand metformin, statins. They have clear, specific indications. Psych meds are relatively unknown, and are used for a million different psych diagnoses

They are not used for a million different psych diagnoses, but a lot of the medications do overlap because you're dealing with a relatively small portion of the body. Mental illness is localized to the brain, so it makes sense that the mechanism of action of the psych meds can treat a number of conditions caused by the brain. Much like antibiotics work on a number of bugs, psych drugs work on a number of illnesses.

And why do people respond to one SSRI and not another?

For the same reason some respond substantially to low-dose statins without problems and others just get myopathy without any significant decrease in their LDL.

There is no way to predict how a patient responds to an antipsychotic - or which is best for them. Did the medication actually help?

The majority of people who have a condition indicated respond to antipsychotics. If you have to ask if the medication actually helped, then you spent a month on psych and you either didn't see someone with a condition that necessitated the use of antipsychotics (which means you had a sub-par psych rotation), you didn't understand the course of the patient's illness, or you were too busy criticizing the field to pay attention to what was happening.

3. Whiny baby syndrome - yeah, I know the patients believe they have a problem

This statement right here is why you have trouble respecting psychiatry. I hope that you are never hit with such hard blows that it leads to depression or anxiety or PTSD. These are MEDICAL problems in which the brain, the same one that tells you to spout such absurd things on a message board, stops working the way it has and promotes actions that create chaos in your life. You should be thanking God that you've never been affected by such problems.

But a large proportion of them have problems that I personally say "so what? This is not even close to an actual problem. Grow up."

Because you have trouble seeing and empathizing beyond your own life.

 

[Anastomoses]

2. And why do people respond to one SSRI and not another? There is no way to predict how a patient responds to an antipsychotic - or which is best for them. Did the medication actually help?

3. Whiny baby syndrome - yeah, I know the patients believe they have a problem. But a large proportion of them have problems that I personally say "so what? This is not even close to an actual problem. Grow up." Obviously I'm not talking about psychotics, more depression/adhd/anxiety. And a lot of them still receive medication. Do they actually need it? I would argue no for a lot of the patients I saw.

Would like to hear thoughts on those points.

2. We just don't know enough about the mind/brain. I, too, have heard this from people I've run across and apparently these drugs must be sampled and results vary with patients. But the number of people who have felt huge life improvements is startling.

3. You already know I'm a big hater of whiny baby syndrome Yet...when we talk about actual medical care, I don't feel comfortable making any call which doesn't in some way enhance a patient's life. If someone has come to seek help - and you believe their story to be accurate, there should be significant effort made to uplift. Psychological pain - even in those who don't exhibit things in polite company - can be excruciating and a huge subtraction to fulfillment. If medication can help, I'm a fan.

All of this really just shows that psychiatry has more complications and lesser knowns to work with so must be extra vigilant and well-trained. All the unknowns of the mind in fact make me very uneasy with both psychiatry and neuro. That may very well be the medicine that is still being done at some point when all the other mechanical things have been figured out.

3. You've basically illustrated the problem of egocentrism. In attempting to understand and interpret the consciousness of another human being we are stuck with the tool of our own consciousness which we know best. It takes a certain kind of person to be able to reimagine the possibility of the patient's unique consciousness through their experience.

I'll give an example of my egocentrism. I've had multiple back surgeries after a work injury and was on heavy round the clock narcotics for 2 years. After my 2nd major surgery and my wound healed I told myself one day I'm not taking any more narcotics. Period. And I didn't. And went into violent withdrawal. I was curled up in the fetal moaning, waiting for it to pass.

So on my addiction psychiatry rotation I was having trouble empathizing with heroine addicts and why they seemed convinced they would die if they didn't get their suboxone.

I asked my seniors on the psych forum about my rejection of their experience. Learned from them. And after thinking about it decided I was stuck with the problem of viewing things through my own consciousness which had the resources and ability to go cold turkey. And that not everyone was me.

This is both the problem of the doctor/patient relationship in psychiatry and why it is so fascinating. It requires the commitment to imagining the consequences of alien consciousness to our own.

Really enjoyed reading this.

 

[Mad Jack]

I went in with an open mind into this class (bear in mind I'm only about to finish MS1) but the course has been pushing me away from pursuing the specialty.


ADHD...at least in part medicalizing a normal part of childhood. More boys than girls have it? Maybe it's because boys are more hyperactive.

Homosexuality was taken out of the DSM largely because of political pressure...makes the entire DSM seem superficial.

One of our lecturers made a case that perhaps racism should be considered a disorder...well then most everyone back in the day would have been labeled with a disorder...way too socially constructed.

About 10% of Americans are on anti-depressant meds. Whatever happened to toughing it up and going with the ebbs and flows of life?

Of course pharmacotherapy has a place and has helped many people but as it's set up now psychiatry (and a lot of medicine) seems to over-medicate and create syndromes and disorders where none exist.

Anyone else? I'm sure I'm not the only one.

If you've got a bunch of people coming in with major depression and you tell them to "toughen up and move with the ebb and flow of life" you might as well offer your patients a complimentary noose with your card if you go into psych.

 

[Wordead]

Groan. I will respond to all this when I have time. The 5 docs 5 dx 5 tx was hyperbole obviously, no patient sees 5 psychiatrists.

 

[Nasrudin]

Groan. I will respond to all this when I have time. The 5 docs 5 dx 5 tx was hyperbole obviously, no patient sees 5 psychiatrists.

You don't know the half of groans. Trying to help people no one wants while doing a thing most resent vaguely and yet passionately. Your points so far are not unknown to us. And yet here we are the mental health care team vis a vis the patients who come to us willingly or otherwise.

While you're taking your time to respond. Think about the point you want to make. And make it interesting.

 

[235009]

I'll start by saying that a good psychiatrist is worth his/her weight in gold whether in the inpatient or outpatient setting and that I have nothing but the utmost respect for the profession. I certainly wouldn't be able to deal with much of what they have to deal with!

That being said some of the absurdly rabid responses to OP are completely out of line. I'll start with one of the worst offenders below:

1) You don't seem to understand the difference between ADHD and variants of normal.

2) I'm not sure how this makes the entire DSM invalid. There's no doubt that the production of the DSM is a politically motivated process. A lot of $$$ is riding on the ability of certain unusual/abnormal traits to be classified as a "disorder."

3) I'm not sure how thoughts or opinions are a mental disorder, but ok. That's pretty disappointing if a practicing psychiatrist made that statement. It shows a complete lack of understanding of mental illness.

4) Ebbs and flows of life? Lol, ok. Again, failing to understand the difference between a bone fide disorder and variants of normal.

5) The fact that mental illness is more difficult to define and characterize does not mean that it is not worth treating. You're right in that psychopharmacology leaves much to be desired. Let me know what you think about that, though, after you've seen someone who is fully psychotic make a complete 180 after being treated with antipsychotics.

Troll harder brah.

1. ADHD is comically overdiagnosed. I had a discussion about this with a child neurologist when I was a fourth year. Let me explain why. Elementary school classes in the US are extremely crowded and it is in the best interest of the teacher to keep the kids docile and quiet so he/she can get through the lesson and check all the government-mandated boxes. So rather than trying to deal with a disruptive child it's much easier to complain to the parent have them take the child to a psychiatrist or neurologist for evaluation which includes as one of the two criteria a report from the teacher that the child is disruptive. Needless to say the teacher will fill out a slam dunk evaluation. The other part is having the parent corroborate that the child acts like this at home which is typically the case (and sometimes the parent feels bullied into it by the teacher through threats of punishment, suspension, expulsion, or placing the child in a remedial class). So Johnny ends up getting drugged up so he can sit still and shut up in class. The doctor basically plays no role in the matter since the criteria is almost exclusively subjective evaluations by non-physicians.

2, 3. even a lot of psychiatrists disagree with many parts of the new DSM. Just look at the changes in personality disorders to see how politically motivated some of these diagnoses are. The point about racism is completely absurd and is actually a perfect example of how imperfect the DSM is. I would argue that racism is probably more inherent/prevalent (just look at basically everyone outside certain parts of the US, even Europe) and we have conditioned ourselves into becoming more inclusive.

4, 5. The criteria for MDD is actually one of the better ones. The problem is that our mental health system REALLY sucks and it's basically impossible to get certain people into psychotherapy therefore there's a much lower threshold for prescribing antidepressants since that's easily available and always covered. On top of that the evidence behind antidepressants is pretty weak and points to the fact that the majority of the benefit is actually placebo effect... look it up, there was even a story on 60 minutes (or some other news show) about it.... a FM attending showed it to us when I was in med school

 

[NickNaylor]

I'll start by saying that a good psychiatrist is worth his/her weight in gold whether in the inpatient or outpatient setting and that I have nothing but the utmost respect for the profession. I certainly wouldn't be able to deal with much of what they have to deal with!

That being said some of the absurdly rabid responses to OP are completely out of line. I'll start with one of the worst offenders below:



1. ADHD is comically overdiagnosed. I had a discussion about this with a child neurologist when I was a fourth year. Let me explain why. Elementary school classes in the US are extremely crowded and it is in the best interest of the teacher to keep the kids docile and quiet so he/she can get through the lesson and check all the government-mandated boxes. So rather than trying to deal with a disruptive child it's much easier to complain to the parent have them take the child to a psychiatrist or neurologist for evaluation which includes as one of the two criteria a report from the teacher that the child is disruptive. Needless to say the teacher will fill out a slam dunk evaluation. The other part is having the parent corroborate that the child acts like this at home which is typically the case (and sometimes the parent feels bullied into it by the teacher through threats of punishment, suspension, expulsion, or placing the child in a remedial class). So Johnny ends up getting drugged up so he can sit still and shut up in class. The doctor basically plays no role in the matter since the criteria is almost exclusively subjective evaluations by non-physicians.

2, 3. even a lot of psychiatrists disagree with many parts of the new DSM. Just look at the changes in personality disorders to see how politically motivated some of these diagnoses are. The point about racism is completely absurd and is actually a perfect example of how imperfect the DSM is. I would argue that racism is probably more inherent/prevalent (just look at basically everyone outside certain parts of the US, even Europe) and we have conditioned ourselves into becoming more inclusive.

4, 5. The criteria for MDD is actually one of the better ones. The problem is that our mental health system REALLY sucks and it's basically impossible to get certain people into psychotherapy therefore there's a much lower threshold for prescribing antidepressants since that's easily available and always covered. On top of that the evidence behind antidepressants is pretty weak and points to the fact that the majority of the benefit is actually placebo effect... look it up, there was even a story on 60 minutes (or some other news show) about it.... a FM attending showed it to us when I was in med school

I don't disagree with anything you said. Unfortunately that's not what the OP said, nor did you subtly yet nonetheless infer that psychiatry is a crock of **** (except for bipolar disorder apparently) not worthy of consideration. Even then you are cherry picking problems, which I could just as easily do with any field of medicine.

So perhaps the lesson learned is that we should be careful with what is said and ensure that what is said is what is actually meant.


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[KnuxNole]

Fair point. As I used the phrase, I'll respond with my opinion.

1. Diagnoses - we all rotate through psych. We all see how random diagnoses can be - 5 psychiatrists, 5 diagnoses, 5 different treatments. If the attendings can't even agree on what a patient has, how are you supposed to agree on a course of action? What good is any "study" if you can't even be sure if the study population actually has the disease?

2. The mechanism and effects being known. We understand metformin, statins. They have clear, specific indications. Psych meds are relatively unknown, and are used for a million different psych diagnoses. And why do people respond to one SSRI and not another? There is no way to predict how a patient responds to an antipsychotic - or which is best for them. Did the medication actually help?

3. Whiny baby syndrome - yeah, I know the patients believe they have a problem. But a large proportion of them have problems that I personally say "so what? This is not even close to an actual problem. Grow up." Obviously I'm not talking about psychotics, more depression/adhd/anxiety. And a lot of them still receive medication. Do they actually need it? I would argue no for a lot of the patients I saw.

Would like to hear thoughts on those points.

For #3, it might be easy for you, but for a LARGE amount of people, saying "grow up" or "deal with it", will never, ever work as long as they live. CBT is very helpful, and it's very possible they might not even need medications!

 

[BobbyB]

For #3, it might be easy for you, but for a LARGE amount of people, saying "grow up" or "deal with it", will never, ever work as long as they live. CBT is very helpful, and it's very possible they might not even need medications!

grow up and deal with it in psychiatry is like telling patients diet and exercise in IM/FP haha

 

[DermViser]

I'll start by saying that a good psychiatrist is worth his/her weight in gold whether in the inpatient or outpatient setting and that I have nothing but the utmost respect for the profession. I certainly wouldn't be able to deal with much of what they have to deal with!

That being said some of the absurdly rabid responses to OP are completely out of line. I'll start with one of the worst offenders below:

1. ADHD is comically overdiagnosed. I had a discussion about this with a child neurologist when I was a fourth year. Let me explain why. Elementary school classes in the US are extremely crowded and it is in the best interest of the teacher to keep the kids docile and quiet so he/she can get through the lesson and check all the government-mandated boxes. So rather than trying to deal with a disruptive child it's much easier to complain to the parent have them take the child to a psychiatrist or neurologist for evaluation which includes as one of the two criteria a report from the teacher that the child is disruptive. Needless to say the teacher will fill out a slam dunk evaluation. The other part is having the parent corroborate that the child acts like this at home which is typically the case (and sometimes the parent feels bullied into it by the teacher through threats of punishment, suspension, expulsion, or placing the child in a remedial class). So Johnny ends up getting drugged up so he can sit still and shut up in class. The doctor basically plays no role in the matter since the criteria is almost exclusively subjective evaluations by non-physicians.

----- You do know there are child psychiatrists right? Yeah, they're going to keep writing drugs relying on non-physician evaluations. Parents are not easily bullied. They want help for their child and aren't going to kowtow to a teacher.

2, 3. even a lot of psychiatrists disagree with many parts of the new DSM. Just look at the changes in personality disorders to see how politically motivated some of these diagnoses are. The point about racism is completely absurd and is actually a perfect example of how imperfect the DSM is. I would argue that racism is probably more inherent/prevalent (just look at basically everyone outside certain parts of the US, even Europe) and we have conditioned ourselves into becoming more inclusive.

A lot of doctors disagree with their "Bible" of their field. What's your point?

4, 5. The criteria for MDD is actually one of the better ones. The problem is that our mental health system REALLY sucks and it's basically impossible to get certain people into psychotherapy therefore there's a much lower threshold for prescribing antidepressants since that's easily available and always covered. On top of that the evidence behind antidepressants is pretty weak and points to the fact that the majority of the benefit is actually placebo effect... look it up, there was even a story on 60 minutes (or some other news show) about it.... a FM attending showed it to us when I was in med school

Yes, you truly are a fool if you think it's placebo affect.

 

[Smokemont]

I think the stat our psych prof shared with us was something like 50/50 on SSRI placebo effect, but that's neither here nor there.

Continue...

 

[KnuxNole]

grow up and deal with it in psychiatry is like telling patients diet and exercise in IM/FP haha

True, and some physicians tell them "Oh just focus on diet and exercise and you'll be fine!" without telling them HOW to do it, or expect the patient should have an easy time with that "advice", not knowing that the average American has NO idea what that means haha. It may be obvious to you and me, but we have to remember who our audience is!

 

[ohioguy]

If you've got a bunch of people coming in with major depression and you tell them to "toughen up and move with the ebb and flow of life" you might as well offer your patients a complimentary noose with your card if you go into psych.

Perhaps that "toughen up quote" was insensitive on my part but I didn't say that meds aren't appropriate in certain patients. My point was it seems to be given out like candy.

We are just finishing up Psych at my school as well.

It was/is awesome. Best course of first year. Pretty damn relieving to finally have a course with material that isn't painful (or at best, tolerable) -- but instead enjoyable -- to study at length.

Apparently it's the "different strokes, different folks" thing at play... Which is great really, because the kind of person that really enjoys biochemistry (random example of cut/dry hard sci) might not enjoy something like psych...and vice versa.

My professor also made a note about racism, it makes me wonder if we go to the same school -- or if it is a common topic for psych professors to pontificate about during lecture. At least in my professor's defense, he did not claim that it was a disorder (nor tried to seriosuly convince us) -- rather it was a game of devil's advocate: "here is the criteria of how we determine who has disorder XYZ", "look, I can make racism fit that mold", "what do you think? yay or nay?"

In regards to politics (e.g. homosexuality no longer being a d/o), it might be a touch of that and a touch of the fact that many of the disorders are measured against what is "normal" by society. So for example, the public does not accept psychosis as a "normal" state of mind for people to go about their day in, the public does not accept purging as a "normal" ritual after meals, the public does not accept not being able to sleep as "normal".

Half a century ago, society did not accept homosexuality as a normal thing. Today, by and large, society accepts it as "normal". It makes sense then for the medical community to no longer consider it a disorder (something defined as: "a derangement or abnormality of function").

I think you mention "socially constructed" in your post. I imagine you would agree that the above example would have society playing a large role in constructing that DSM change.

That's how it goes though. Psych is basically the most person-focused specialty in medicine to begin with (disclaimer: personal opinion). Pretty much every other specialty has a good amount of lab values to fall back on or measure [or images to examine] in order to arrive/confirm a diagnosis. Comparatively, in psych, it starts with the patient and ends with the patient.

EDIT: In retrospect "most person-focused" sounds a bit emotionally charged and insinuates that perhaps other specialties don't care about the person. Def not saying that.

We actually do go to the same school. The psych syllabus for us is like the Harry Potter of syllabi, not painful at all and slightly enjoyable. In regard to the racism thing, maybe we remember it differently, but to me, the fact that the lecturer would even entertain the notion of racism being a disorder pushed me away... I just started imaging a bunch of old men arguing over what should and should be considered a disorder in the DSM. Same thing with medicalizing (almost victimizing) substance use (why of course as doctors we have to treat anything and everything that comes our way, bring in the crackheads/alcoholics!)...seems to be little room left for responsibility on behalf of the patient (although I'm not saying cases of SUD aren't worthy of meds/treatment). In regard to psychiatry labeling not "normal" behaviors as disorders...sure there are real psychiatric disorders worthy of medication but I'm not comfortable with an institution telling us what's deviant and what's not, especially when that view seems to fluctuate by the decade.

1) You don't seem to understand the difference between ADHD and variants of normal.

2) I'm not sure how this makes the entire DSM invalid. There's no doubt that the production of the DSM is a politically motivated process. A lot of $$$ is riding on the ability of certain unusual/abnormal traits to be classified as a "disorder."

3) I'm not sure how thoughts or opinions are a mental disorder, but ok. That's pretty disappointing if a practicing psychiatrist made that statement. It shows a complete lack of understanding of mental illness.

4) Ebbs and flows of life? Lol, ok. Again, failing to understand the difference between a bone fide disorder and variants of normal.

5) The fact that mental illness is more difficult to define and characterize does not mean that it is not worth treating. You're right in that psychopharmacology leaves much to be desired. Let me know what you think about that, though, after you've seen someone who is fully psychotic make a complete 180 after being treated with antipsychotics.

Troll harder brah.

I already said in my OP that I think pharmacotherapy has a place and has helped many people...like the psychotic patient you mentioned. However, there's, let's say, a disorder like ADHD, variants of normal...and then a whole bunch of gray area in between. My issue is with meds being prescribed when the patient may be/is probably better off without it or doesn't need it at all.

 

[Frazier]

We actually do go to the same school. The psych syllabus for us is like the Harry Potter of syllabi, not painful at all and slightly enjoyable. In regard to the racism thing, maybe we remember it differently, but to me, the fact that the lecturer would even entertain the notion of racism being a disorder pushed me away... I just started imaging a bunch of old men arguing over what should and should be considered a disorder in the DSM. Same thing with medicalizing (almost victimizing) substance use (why of course as doctors we have to treat anything and everything that comes our way, bring in the crackheads/alcoholics!)...seems to be little room left for responsibility on behalf of the patient (although I'm not saying cases of SUD aren't worthy of meds/treatment). In regard to psychiatry labeling not "normal" behaviors as disorders...sure there are real psychiatric disorders worthy of medication but I'm not comfortable with an institution telling us what's deviant and what's not, especially when that view seems to fluctuate by the decade

Haha, I can certainly believe that. Blowing through lectures in fast forward -- sometimes emphasis is lost. So perhaps what appeared to be as a brief aside to me was more of a focus for others in the class.

About the second point, it is a real issue that a lot of people seem to be uncomfortable with... solace to a small degree hopefully to know you aren't alone. Critical thinking and "questioning how/why things are the way they are" in healthcare settings is a great quality to have, IMO, so I think you are doing a good job.

 

[NickNaylor]

My issue is with meds being prescribed when the patient may be/is probably better off without it or doesn't need it at all.

Well... duh. If it were that easy, don't you think we wouldn't have this problem in the first place? Only in the fantasy land of MS1 are the scenarios clear and the indications for treatment black and white. This is doubly true in psychiatry. I'm not sure how that damns the whole field as you seem to imply.

 

[DermViser]

Well... duh. If it were that easy, don't you think we wouldn't have this problem in the first place? Only in the fantasy land of MS1 are the scenarios clear and the indications for treatment black and white. This is doubly true in psychiatry. I'm not sure how that damns the whole field as you seem to imply.

Wait, you mean medicine isn't like an NBME/USMLE exam question? I always felt like I saved patients by answering the clinical vignette questions correctly. I was more mad that I couldn't bill for those clinical vignettes.

 

[NickNaylor]

Wait, you mean medicine isn't like an NBME/USMLE exam question? I always felt like I saved patients by answering the clinical vignette questions correctly. I was more mad that I couldn't bill for those clinical vignettes.

"Sorry that your husband died, but we followed the treatment that gets us the right answers on multiple choice exams to the T."

 

[Nasrudin]

Again, exercise and diet modification are better than statins and anti-hypertensives and yet psychiatry is prosecuted for its pharmacotherapy whereas with other fields it is not. So the why in this selective bias is just as good a starting point as what are the problems with the use of the DSM.

Additionally it is one thing to hear about the underuse of psychotherapy from a skilled clinical psychologist. It's quite another to hear of it's lamented neglect from people who don't know a f'n thing about what it is, how it's used effectively, what the problems are with deploying it widely, or even what it is useful for, and what forms of it are in fact useful for this or that.

So...what you have is vague unease with psychiatry and mental illness...filtered through the neurotic mind of medical students...who have no intention of doing anything for the mentally ill except likely neglecting them when on their service because they think their problems are fake. Who then want to be taken seriously and treated as if they have something interesting or original to say on the matter when they talk about over medication and over diagnoses. Toddlering their way past the fact that most of these diagnoses are made by PCP's and often what the psych does is counteract that.

But it's ok to be a toddler and throw poop at psychiatry. Because it's not a real field like medicine or surgery.

 

[DermViser]

"Sorry that your husband died, but we followed the treatment that gets us the right answers on multiple choice exams to the T."

I planned on bringing in a respresentative from the NBME, Kaplan, USMLEWorld, Lippincott Williams and Wilkins, and McGraw-Hill, as character witnesses in my first malpractice lawsuit. I'm sure patients will understand that I was just following the flow chart algorithm. I'll just explain that I can't understand why things went so wrong. I mean, it went absolutely fine when I did the same on USMLE Step 3 CCS.