Carlat and Overzealous Psychiatrists

[billypilgrim37]

Benzos absolutely destroy CBT? Show me the journal articles that show that please.

I was clearly speaking in a hypothetical to prove a point, and I acknowledged this in the rest of my hypothetical about the actual problems with real benzos. Sorry if I can't produce a journal article about the mythical side-effectless benzo-like magic pill that I am postulating. And that is from clinical experience. If benzos didn't, you know, eventually kill people and/or turn them into addicts, then anxiety disorders would be about as easy to treat as an ear infection.

All treatments for PTSD suck?

Well, yeah, they do. People with PTSD suffer a lot. Both the psychological and psychiatric community continue to fail these people. It's not because we aren't trying. Likewise, the oncologic community continues to fail people with cancer, and the treatments for cancer suck. It's not because we're not dumping buckets of money into onc research.

Psychologists not being smart enough?

Dude, check the context. The inverse (and equally true) statement would be that "psychiatrists aren't smart enough to cure schizophrenia." The point was that if suddenly schizophrenia became a disorder that was best treated behaviorally, it wouldn't change that it's fundmamentally neurologic disorder. I think psychologists are plenty smart.

You just turned this argument into an immature one so I won't comment any further. Sorry.

I post on here a lot (because apparently I have too much free time, despite not having any free time), and my tone is generally pretty playful. If you read my whole post again in a Chris Farley-esque voice, that might be closer to the way I intend for this to come across. (It was also written at 3AM after an ED shift, so...) Some conversations are better held over a pitcher of beer, and this is one of them. So accept my apology if I came across as a jerk. I probably do a lot. And I'm a pretty thin-skinned narcissist who certainly wants to be well liked.

My problem with your dichotomy is two-fold: a) it sounds like something Descartes would say, and when Descartes wasn't doing algebra, he was generally an idiot, and b) much of your dichotomy seems to hinge on whether the disorder is best treated behaviorally or medically. That seems silly, and sets up a split that doesn't need to be there. There shouldn't be this tension between psychiatry and psychology. We're fundamentally treating the same diseases, it's just that one of us gets excellent training in top-down approaches, and the other from bottom-up approaches (don't ask me which is which!). And our patients deserve appropriate considerations of both treatments when indicated. There are some people that just need to see you, there are some people that just need to see us, and there are many people who should see both. That doesn't mean the disorders are suddenly different because of that.

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[sunlioness]

YES!

A much better strategy would be to continue to reward English majors and philosophy majors with medical school admissions. None of my classmates wanted to talk about William Carlos Williams with me, no matter how many times I photocopied poems and short stories for small groups.

Aw, I would have . I'm a history major who didn't understand why my classmates didn't share my fascination for Yersinia pestis. Yersinia pestis is cool. I don't want it. I don't want anyone else to have it either, but you gotta have respect for a little bacteria that helped bring about the renaissance.

 

[AleksPsych]

Based on your other posts, you seem to imply that diseases are classified as impaired functions in addition to known structural abnormalities. The two definitions I provided, which basically stated the same thing, were meant to counter your incorrect assumptions regarding mental health diseases.

You seem to imply that psychiatrists try to medicalize mental health illness for our own gains. This is another incorrect assumption or allegation as after years in medical school and internship in various other medical specialties, we all know that there is much uncertainy regarding the etiologies of illness throughout medicine and not just in mental health.

Do bribes work all the time with substance users? There are numerous studies showing genetics and neural circuit dysfunctions in substance use which behavioral therapy can help somewhat. Another very difficult disease to treat.

Regarding your last point, I find it fascinating that psychologists, with minimal or zero medical training, often make generalize statements regarding the topic.

I do believe diseases are classified based on impaired bodily functions. Of course, this is generally true but not true in all cases. I'm not being black and white here, and I noticed there is a tendency to take nuanced statements and make them more black and white.

I do not believe psychiatrists medicalize for "gains." I believe psychiatrists are trained the medical model and this is really the only way they typically know how to conceptualize presenting difficulties. Psychologists conceptualize most mental disorders in a less reductionistic way.

Of course bribes do not work all the time with substance dependent patients. No treatments for any conditions work all the time. This does not mean SUDs are not best seen as behavioral disorders (albeit influenced by the brain) and not brain diseases. Psychiatrists like Satel and McHugh have written more extensively on this topic, and a psychologist Heyman has written a book on this topic.

What is medical training? Going to medical school? Does it partially involve learning about diseases? If psychologists are treating diseases of the brain as you suggest then we do have some medical training. I, of course, do not agree in the slightest.

Btw, I appreciate all your comments.

 

[nancysinatra]

Can I point something out? I agree with some things that AlexPsych is saying, for example that there is a difference between Alzheimers and substance abuse, and between seizure disorders and conduct disorder. This difference is obvious!! Most medical doctors would agree--if you do a brain biopsy of an alzhiemers patient, you will find neurofibrally tangles and amyloid plaques. Also on CT/MRI you could see atrophy. Not so with substance abuse. Yes, we have an ever increasing amount of information about what's happening in the brains of substance abusers. However, we don't have enough to teach medical students, "this is what to look for on this or that test."

And also, it's true--with neurodegenerative diseases like alzheimers, the diseases proceed inexorably and no "talk therapy" or "bribing" or whatever you want to call it will have an effect on the progression of the illness. I mean, does anyone want to argue this? Even our medications are measly for alzheimers. This makes it different from substance abuse, where a person can hope to recover through interventions involving not only mediations but therapies that are mediated by other people (bribing, psychotherapy...).

Somewhat similar with seizures vs conduct disorder. As far as I know, seizures (ideally) can be identified on EEG and sometimes even a cause is localized on MRI. I don't know of any "tests" for conduct disorder or targeted treatments (but I haven't done much child psych) however I highly doubt there's a medication that actually treats the pathophysiology in some directed pharmacological method. Nonetheless, it is the child's brain, certainly not their foot, that is affected (I'm guessing, anyway). But we have even less information about where and how something has gone wrong than we do with substance abuse. Luckily we do know that families and environment relate to the illness and we can approach it from that angle. With other "brain" illnesses, we CANNOT treat the "family" and expect to have any impact--for example, would you treat herpes encephalitis (also a brain disease! also effects behavior, too!) that way? No!!! So there must be some kind of difference...

Ok my point is, this discussion is ridiculous. Psychiatrists vs psychologists is a stupid argument. You could have the same disagreement with psychiatrists vs neurologists. It's hair splitting. There's so much we don't know about the brain! Whatever the "brain/mind" is, that is a question for philosophy. Diseases of the brain/mind whatever are each unique, but we don't know that much about a lot of them. We are learning more every day though.

 

[AleksPsych]

Can I point something out? I agree with some things that AlexPsych is saying, for example that there is a difference between Alzheimers and substance abuse, and between seizure disorders and conduct disorder. This difference is obvious!! Most medical doctors would agree--if you do a brain biopsy of an alzhiemers patient, you will find neurofibrally tangles and amyloid plaques. Also on CT/MRI you could see atrophy. Not so with substance abuse. Yes, we have an ever increasing amount of information about what's happening in the brains of substance abusers. However, we don't have enough to teach medical students, "this is what to look for on this or that test."

And also, it's true--with neurodegenerative diseases like alzheimers, the diseases proceed inexorably and no "talk therapy" or "bribing" or whatever you want to call it will have an effect on the progression of the illness. I mean, does anyone want to argue this? Even our medications are measly for alzheimers. This makes it different from substance abuse, where a person can hope to recover through interventions involving not only mediations but therapies that are mediated by other people (bribing, psychotherapy...).

Somewhat similar with seizures vs conduct disorder. As far as I know, seizures (ideally) can be identified on EEG and sometimes even a cause is localized on MRI. I don't know of any "tests" for conduct disorder or targeted treatments (but I haven't done much child psych) however I highly doubt there's a medication that actually treats the pathophysiology in some directed pharmacological method. Nonetheless, it is the child's brain, certainly not their foot, that is affected (I'm guessing, anyway). But we have even less information about where and how something has gone wrong than we do with substance abuse. Luckily we do know that families and environment relate to the illness and we can approach it from that angle. With other "brain" illnesses, we CANNOT treat the "family" and expect to have any impact--for example, would you treat herpes encephalitis (also a brain disease! also effects behavior, too!) that way? No!!! So there must be some kind of difference...

Ok my point is, this discussion is ridiculous. Psychiatrists vs psychologists is a stupid argument. You could have the same disagreement with psychiatrists vs neurologists. It's hair splitting. There's so much we don't know about the brain! Whatever the "brain/mind" is, that is a question for philosophy. Diseases of the brain/mind whatever are each unique, but we don't know that much about a lot of them. We are learning more every day though.

Thank you nancysinatra!!

I did not think I was making any radical, bizarre observations in making distinctions between neurological conditions/some psychiatric diseases and other psychiatric disorders.

 

[AleksPsych]

Well, yeah, they do. People with PTSD suffer a lot. Both the psychological and psychiatric community continue to fail these people. It's not because we aren't trying. Likewise, the oncologic community continues to fail people with cancer, and the treatments for cancer suck. It's not because we're not dumping buckets of money into onc research.

I agree, people with PTSD do suffer immensely, and the psychological/psychiatric communities do fail these people because evidence-based are typically not provided in the community. I do believe prolonged exposure therapy is extremely effective in the majority of PTSD patients. There is scientific literature to support this, and I've seen it with my own PTSD patients. SSRIs have some impact on the treatment of PTSD as well, but the benefit is less than PE.

I post on here a lot (because apparently I have too much free time, despite not having any free time), and my tone is generally pretty playful. If you read my whole post again in a Chris Farley-esque voice, that might be closer to the way I intend for this to come across. (It was also written at 3AM after an ED shift, so...) Some conversations are better held over a pitcher of beer, and this is one of them. So accept my apology if I came across as a jerk. I probably do a lot. And I'm a pretty thin-skinned narcissist who certainly wants to be well liked.

I appreciate that. Thanks.

My problem with your dichotomy is two-fold: a) it sounds like something Descartes would say, and when Descartes wasn't doing algebra, he was generally an idiot, and b) much of your dichotomy seems to hinge on whether the disorder is best treated behaviorally or medically. That seems silly, and sets up a split that doesn't need to be there. There shouldn't be this tension between psychiatry and psychology. We're fundamentally treating the same diseases, it's just that one of us gets excellent training in top-down approaches, and the other from bottom-up approaches (don't ask me which is which!). And our patients deserve appropriate considerations of both treatments when indicated. There are some people that just need to see you, there are some people that just need to see us, and there are many people who should see both. That doesn't mean the disorders are suddenly different because of that.

Upon reflection of my previous posts, I would say that I presented my dichotomy inappropriately. I think the post by nancysinatra right above more accurately reflects my view.

Top-down = psychologists, bottom-up = psychiatrists, hahah.

I guess I never thought I treated brain diseases in psychotherapy. Hmmm, neuroplasticity... I need to read up on that a bit more.

 

[Therapist4Chnge]

I agree, people with PTSD do suffer immensely, and the psychological/psychiatric communities do fail these people because evidence-based are typically not provided in the community. I do believe prolonged exposure therapy is extremely effective in the majority of PTSD patients. There is scientific literature to support this, and I've seen it with my own PTSD patients. SSRIs have some impact on the treatment of PTSD as well, but the benefit is less than PE.

Edna Foa and colleagues have done some great work with PE and trauma survivors. Their initial studies suggest that using prolonged exposure can significantly reduce PTSD symptoms, and the treatment can be done in about 10 sessions. I admittedly have reservations about a more manualized treatment, but I have seen some excellent results with their protocol. VAs are starting to implement it with some solid results.