Monday, October 10, 2011

Guest Blogger Dr. Jesse Hellman: What are the Limits of Psychiatry?

Recently a colleague and I were talking about a question that had been posted on our psychiatric society's Listserv. The question had to do with the age at which a parent would tell their child he had been adopted, and who the birth parents were. This question is quite complex, depending on a multitude of factors. Child psychiatrists responded, as did adult psychiatrists. Is this a question, though, for Psychiatry? One might argue that the question has nothing to do with mental illness. But does our field define itself only as addressing mental illness?

A few days ago in the NY Times there was an OP-ED piece in which the author touted brain studies as showing that we do not just "like our iPhones" but "love our iPhones." When I read it I was surprised, as the idea of whether one might "love" an iPhone (or, for me, my camera or sports car) never occurred to me: Of course I do. What was surprising was the apparent sense of discovery by the author of a phenomenon that Freud had clearly described well over eighty years ago. He invented the word "cathected" to describe that we can "cathect" or imbue any particular thing, or even idea, with erotic energy and so love it with the intensity we have for living things. He explained that that cathected energy can be withdrawn from these things as well as from people, and the formerly loved object discarded instantly.

So psychiatry, to me, includes psychology in its broadest sense as well as the complexities of human interaction. In my own practice the most difficult and important issues are not usually the questions of medication but those that have to deal with all the issues that  beset the patient that are then brought up in their sessions: getting promoted at work, the problems of a marriage, the competitive strivings within a family or its workday substitutes, the losses one faces inevitably in life, and so on. Almost infinite variety.

So how do others address this question? Just what is Psychiatry?


rob lindeman said...

[Darn! I can't find the youtube video of this exchange]

"Tracy: Dr. Spaceman, when you get my DNA, will you be able to tell what kinda diseases I'm gonna get, or help me remember my ATM PIN code?"

Dr. Spaceman: Of course! Science is... whatever we want it to be"

Thus also with Psychiatry?

wv = slywrodo. 1980's punk/ska/rap group, disbanded after failing to sell any albums (Dad? What's an 'album'?)

Sunny CA said...

From a patient perspective, I would consider bringing up anything important to me with my psychiatrist, but usually that is people for me, not objects. Objects don't cause me any angst, but people do.

I don't agree with Freud. I don't "love" my objects with erotic energy. I do have objects that especially appeal to me, though, and Apple is a company I "love", but not erotically. I also "love" my (really wonderful) pens and (light, fluffy, special) down comforters and some books, and my e-reader: NOT erotically, though the down comforter probably comes the closest to being "erotic", except my comforter and I have a platonic relationship.

Dinah said...

So one day, back in my pre-Apple days when my kids were littler, I'm driving in the car and I hear one kid say to the other kid, "Mom's love is divided four ways: 25% for you, 25% for me, 25% for Dad, and 25% for her Palm Pilot. This was before the laptop and the blog (and now the iPhone).

Rob, mostly I agree with you that we don't know we're doing. Seems fine to try and it seems many people get better. It's an interesting journey, so I'm on it. Send the DNA samples and the spaceman to Roy.

SunnyCA, that down comforter sound nice just about now....

Sunny CA said...

Yes. I have to go out in the cold and rain to feed the two feral cats, then I am off to be caressed by my comforter... maybe Freud was right.

Carrie said...

So I told my psychiatrist once that he reminded me of Albus Dumbledore from the Harry Potter series. (He's a Harry Potter fan. I'm in the obsessive fan base...) In the books, Dumbledore doesn't give Harry the answers for many things, but rather waits for Harry to learn them for himself. Harry also realizes at one point that he doesn't know much at all about Dumbledore. I particularly love the interaction in the 7th book.

It took me quite a long time to realize that my psychiatrist wasn't going to have an answer for major problems or dilemmas. We could talk about them, but he wasn't going to answer them in most cases. I liked that aspect of things to an extent - sometimes it was frustrating, but mostly even just talking about things sometimes helped me mull it over more in my head and figure out what I wanted to do.

Dinah - HA! That's a story that sounds similar to one my bioethics professor tells about her kids. She hasn't posted on Facebook nearly as much in the past year, but she has some hilarious stories. :)

jesse said...

There was a good piece on Freud by Gordon Marino in yesterday's NY Times ( I could paste it here but it is somewhat long) - the reason i brought up Freud was just to underline that psychological discussions were totally commonplace in psychiatric circles but are less so today. I wonder whether the emphasis on Med Management has led to topics that once involved all of us to go over to psychologists and social workers. A shame, I think.

Freud did have terms that he used in a particular way, but some of that is due to Strachey's translation. Freud used the word Object to mean the recipient of a "drive," such as when we say "she was the object of his desire." It does not refer to chairs, but it might. The idea is that we can attach our erotic, love, energy to anything. An iPhone, no less a person, can be prized one day and discarded the next.

If you want me to paste Marino's piece let me know.

Anonymous said..., jesse is a psychiatrist who actually deals with issues outside of medication management. Talk about a dying breed.

That question about when to tell a kid he was adopted is so personal that I don't even know it's a question for social workers or psychologists. I think I know how I would handle it...but that's at the discretion of families.

If psychiatry really is pretty much only medication management these days, then I don't even think pscyhiatrists have any business in psychology. I don't even think they should be allowed to prescribe meds unless a psychologist has diagnosed the patient first. No joke. A psychologist can take a little more time with a patient than a psychiatrist and will know better if the patient needs medicating. If the psychologist decides the patient really has an issue worth medicating then the patient can be seen by a psychiatrist for medication. I think this especially for children (sometimes worried parents see things that aren't there).

A friend of mine recently told me he was on Lamictal last year. It was the year after I moved away so I didn't know. I almost spit up my coffee. He was diagnosed bipolar after a 30 minute visit to a psychiatrist. I have NEVER seen this friend act bipolar. Moody yes. Immature absolutely. Bipolar no. He said he spent the year like a zombie and then got off it and went into withdrawal. He realizes now he was not actually bipolar. I could have told him that! I asked him what possessed him to think he was bipolar and he thinks its cuz his best friend is bipolar and the behavior rubbed off on him. I guess this was a situation where the adult, and not parents, were seeing behaviors that weren't really there and making meters out of microns to a psychiatrist.

However, if psychiatrists are willing to really get to understand a patient's psychology (moods and other symptoms), before putting him on a powerful antipsychotic, then they have my blessing to prescribe when they please. If not, I think the psychiatrists first need permission from someone who did a thorough evaluation of the patient.

jesse said...

Actually Anon, there are quite a few psychiatrists who spend a lot of time with their patients and understand a great deal about psychology. I know of very few Medication Management only patients here. The discussions on the Maryland Psychiatric Society listserve are sophisticated and show a wide range of knowledge.

In my experience the psychiatrists here in Baltimore are thorough and thoughtful.

But the basic question I am asking has to do with the the way the profession thinks of itself. The journals, such as that of the American psychiatric Association, no longer have significant articles of a psychological nature. I'm afraid the field is changing.

I'm not sure what "acting bipolar" means but it likely does not describe what we think of as Bipolar I or II. At times an accurate diagnosis can be made in a very short time by someone who has sufficient knowledge or training. Contrary to what you might think, I do not think psychologists do a better job of deciphering who needs medication. I have heard many stories from patients of psychologists or social workers calling an internist and requesting, and getting prescribed, a specific medication. This is not good at all.

Anonymous said...

I would say that you are very correct if you think that the profession has drifted away from psychology and sees itself as medicine centered.

With all due respect for psychiatry, my point is not that a psychiatrist cannot spot a mental illness and diagnose it in a short amount of time. It's the patients that I think have the issue (seeing their issues as bigger than they actually are). I am certain a psychiatrist knows mania when he sees it. But does the patient know mania when he sees it? And can the patient always be objective enough to accurately report on it?

Also, what's wrong with an internist prescribing psych meds after being evaluated by a psychologist or social worker? I would think so long as the diagnosis was correct and the corresponding treatment was right there shouldn't be a problem. Or is there?

jesse said...

The problem is not that internists cannot prescribe if they have sufficient knowledge. The problem is that often (I have heard this a lot) a social worker for example will call the internist and say "this patient should be on Prozac (or Zoloft, or Lamictal, or...)." The social worker really does not know the whole picture with the meds, and the internist is ceding his own judgment on medication to someone without a medical degree or much experience/competence to determine which medication is useful.

What you are saying about the patient is true. If a psychiatrist does his job he takes the time necessary, however long that is, to diagnose correctly. I know many excellent psychologists and social workers. But I also have seen plenty of patients who told me what I am relating above.

I also agree with your other point: psychiatrists who know little about psychology should not act as if they do understand it. Today there are many social workers/psychologists who are far better at psychotherapy than many psychiatrists. When I was in training the intricacy of psychotherapy was a large part of what a psychiatrist was expected to know.

Dinah said...

I think you're all saying the same thing here.
Sometimes diagnosis can be difficult, especially with the broad range of what we've now come to think of as Bipolar Disorder. I usually spend two hours seeing a patient for an evaluation, and even then, I'm sometimes at a loss. The nice thing about seeing people for psychotherapy is that it often does not feel essential that I figure it all out immediately.

Sometimes diagnosis is easy: a patient comes in with obvious and severe symptoms and they know what they have..."I'm depressed" or "I'm having panic attacks..." and the interview confirms that the patient is right.

We all think it's best if the psychiatrist is thoughtful and listens and doesn't rush to decisions based on very little information.

Private practice is not the best place for "med management" quick visits. When a psychiatrist is working in a system---for example, a clinic or a jail-- they are part of a team and they share a chart and often have good communication with the therapists. In the clinic I work in, I see my med management patients with the therapist in the room with us. There's lots of communication.

In medical schools, psychiatry is usually a 4-6 week rotation centered around inpatient units. You can become a doctor and know almost nothing about outpatient psychiatry. It doesn't leave internists in the best places to prescribe.

Anonymous said...

Anon, how do YOU know that your friend wasn't bipolar? Are you a mental health professional? Did you even take an abnormal psych course in college? Bipolar is spectrum illness. Not everyone experiences the dramatic mania associated with the extreme forms of the disease. The "immaturity" you ascribed to your friend could have been his version of hypomania, especially if he wasn't like that all the time.

Sideways Shrink said...

Professor of political philosophy was my first career cathexis. But it became evident quickly that due to demographics I would never have been able to get tenure (and my erstwhile peers are still at one and two year visiting positions). But bailing out of that grad program in the first semester was the best PhD I never got. Psychiatry is engaging my fellow humans regarding the actual struggles of life. As a professor of political philosophy I would have been engaging life in an "about it" way, from a distance. Psychiatry is messy. People cry and there is not an assistant in the room with me holding a suction or an emotion cauderizing machine. I think of cognitive behavioral therapy as a kind of emotional cauderizing. It has its adherents here on the West Coast among psychologists and other various training programs.
I use the metaphor with patients by pinching my fingers that "Medication does this" and then stretch my arms out and say "but the reason for therapy is that life is like this". That is what I use medication for 50% of the time, to control symptoms so that the person can engage in therapy. When in severe suffering no one can reflect on what they are going through and how they got there and how to get out of where they are or how not to get there again. The question of whether maintenance medications are needed becomes clear in the therapy process or the person already knew that coming in.
Within the ethical constraints of the practitioner, psychiatry is delimited as to subject matter of discussion. A brilliant young woman with mild Aspergers once asked me relatively early in treatment "Why am I weird?" I paused for a long time. Then I asked, "Everyone feels weird sometimes. What weirdness do you think you have?" She said, "I can't meet people's eye when I walk down the hallway. I feel like there is something I don't get. I don't understand why." I was on the spot. I took a deep breath. I said, "Well, it could be that you are just an introvert or shy, or it could be that you have a condition called Aspergers Syndrome. Have you heard of that?" "Yes I have. I was wondering about that. I have a series of birth defects and frequently people with that syndrome have some degree of Aspergers and I was wondering if you would think I had it. The genetics researcher couldn't tell, he said, but from what I've read I seem to fit criterion. It is a relief to know."
And there you have the tightrope and the beauty of psychiatry: it is like the rest of medicine in that diagnoses must be given honestly and with tact. However, the diagnoses can be laden with all kinds of meanings and identifications, positive and negative, painful and relieving for the patient that you can not anticipate but must flux with on an existential dime.
My first psych job was in a multi-specialty group practice and this 47 year old psychologist kept LITERALLY falling asleep during therapy sessions. I can not imagine falling asleep in the presence of a patient. People are so unexpected and amazing. I love being awake and witnessing them work out their changes.

jesse said...

SS, you have expressed beautifully what I love about psychiatry. That you felt you could express it here is what I love about Shrink Rap.

Anonymous said...

To the Anon asking how I think I can know my friend is not bipolar. It's in the same way I know my brother is not psychotic and I'm not depressed. It's just not there. And I get that it's a spectrum disorder...but there is a big difference between moody/immature and manic. Even hypomanic is still abnormal and is not a normal mood. Or so I understand.

What is most important for me is that my friend understands what bipolar disorder is, that was his diagnosis, and he told me that he doesn't think he has it. He is also doing fine off his medication. Maybe that will change, but for now I think he is correct that he doesn't have it.

I thought the mood shifts of bipolar were supposed to be noticeable. It's not hidden, in the way that people will hide depression. I'm actually curious what his diagnosis would have been if he had brought family or friends to his pdoc appointment that resulted in the Lamictal. I wonder if they would have described him as acting manic if they had been asked.

If he starts having issues, is convinced he really was bipolar, and goes on a mood stabilizer then he has my support.

rob lindeman said...

Regarding "spectrum disorders", please see this remarkable offering from Neuroskeptic:

"...the same way I know my brother is not psychotic and I'm not depressed. It's just not there"

Incidentally, this is how I know I'm not a hamster (I'm a flea).

wv = yeralki, imalki. Thomas Harris's less successful self-help book

Anonymous said...

Clever article Rob :) That was a good point about calling height a spectrum and yet we don't call it the midget spectrum. Midget is an extreme end of height. Bipolar is an extreme in moods. It might be more accurate to call it a mood spectrum (with bipolar being at one end and people with no feeling at all at another end).

Dinah said...

I'm going to refer the bipolar questioners amongst us back to my post on Mood Disorders 101:

It's possible that a person acting totally non-bipolar, whatever that means, goes a psychiatrist because they are feeling down. In the course of taking a history, the patient notes a period years ago where his mood was elevated (either obviously manic, or a hypomanic state that may not have been obvious to others) and so a diagnosis is made of Bipolar Disorder, based on history, not current behavior or mood state.

Lamictal is not a terribly power mood stabilizer and is usually used to treat depression in people with bipolar disorder because there is thought to be less chance that they will 'switch' to mania and destabilize. The current thinking is that if a patient has bipolar disorder, it's best to avoid antidepressants, or to use them sparingly in conjunction with a mood stabilizer, because they make people cycle more.

So that's how someone can not look bipolar and still get the diagnosis and be put on Lamictal. I don't know if that's what happened here, and this generally does take more than 10 minutes to sort through.

rob lindeman said...

Dinah, now I'm confused. I thought the chemical imbalance theory was discredited. What are we stabilizing?

wv = numpleun. The unit measure of boiled pasta. 10 numpleun = 1 dumpling

Dinah said...

Rob, the chemical imbalance theory was not been dis-credited, it just hasn't been proven (yet). We are stabilizing "mood" which may or may not make sense to you, but patients seem to say that their mood feels more stable, whatever that means (I'm not in their heads) and for whatever that's worth. If you're not someone whose mood varies unreasonably, then it's probably difficult to empathize with (we shrinks try hard)

Anonymous said...


That was a much more concise way of saying what I wanted to say. My doctor is very clear that nothing has been proven and there is so much more to know. As someone who like to have answers for everything, it is tough to accept that but as someone who ends up in a hospital when off meds, I have learned that as much as I hate the not really knowing, the side effects, and just plain taking all those drugs, I would choose to take them over the psychosis that lands me in the hospital when my mood episode has spiralled out of control. No one can promise me that the drugs won't cause long term damage to some part of me or that I won't die sooner of some other disease for having taken the meds. No one can promise the person who has never taken a drug and who is careful with their health that they will not get sick and die either. I do have people tell me to get off that stuff and just meditate or learn to relax and stuff like that. Been there, done that and I still end up in a ward. So the ONLY thing that does stabilize are the drugs. I don't know how, my doctor doesn't know how, not really. Maybe one day they will figure it all out but probably not in my lifetime. I fought for too long against the meds and it did not do me any good. We don't really know the effects of lots of things or why they work.

Marie Gronley said...

I see the limits of a psychiatrist extending out to a position of advocacy for educating and removing the stigma of mental illness. I do my best with each patient and through my website to inform the public that mental illness is a physical condition; every bit as much as diabetes. An organ or system is failing viz. the brain and doesn't regulate the neuro-transmitters, just as the pancreas fails to regulate insulin levels. I have learned that nearly 50% of all patients with a mental disorder will postpone treatment for up to 10 years due to the stigma of mental illness. I find this horrible that someone should suffer with the mental and physical anguish of depression or anxiety for fear of job loss, or humiliation. So my first and foremost goal is to educate about the physiological grounding of mental disorders-and that mocking mental illness is similar to mocking people in wheelchairs. If psychiatry doesn't go to these limits, we will only continue to see the increases of untreated mental illness and society will suffer as well as the patient and family. We all know of the possible nerve and brain damage that may occur when some of these illnesses are left untreated; and the social implications as well.

rob lindeman said...


We do? Forgive me, Dr. Gronley, we do not know any such thing.

wv- anonityp; characterizing the majority of commenters here.

Marie Gronley MD said...

Rob you may wish to google "untreated depression and hippocampal volume loss" with regards to the damage of untreated depression. Scientific claims don't rise to the level of knowledge but are considered "inferences to the best explanation"; therefore, subject to debate. Since my post was beyond the pale of this one issue regarding the damage depression can cause, I have no interest in debating the justification for the findings of the study. None the less for others who may have read my post - they may also read this article for clarification.

rob lindeman said...

Dr. Gronley, I read your last comment several times and had great difficulty understanding what you meant, so I gave up and googled "untreated depression and hippocampal volume loss" instead.

What I found was a small study by Sherine et al, published in AJP. The data did not support the conclusion of the study, that anti-depressants are "neuroprotective". See Dr. Bernard Carroll's letter to the editor (161:1309-1310)

In any case, your assertion that "we all know of the possible nerve and brain damage" that occurs in untreated mental illness is untrue. I desperately hope you are not saying such things to your clients.

wv= kierigne. Belgian device, designed to organize and protect one's kies from being lost.

Sarebear said...

The limits of psychiatry are sometimes dependent on the market/geographic area the psychiatrist(s) is/are practicing in. Specifically, how many there are to serve the population, and/or if there's a MAJOR medical university like Johns Hopkins. I have been wondering lately if the seeming abundance of psychiatrists (especially those who practice/can practice alot of psychotherapy because there isn't such a deluge of patients with high need that most psychiatrists in the area, to meet the need, must do alot of med check type appointments or many people would go without help), especially combined with a major medical university in the area, leads to a situation that might skew the perspective a little bit of those who practice in such an area.

Granted, just because three of my psychiatrists have all been med-management types doesn't mean they
ALL are around here, and granted the fact that all three of mine took insurance MAY have meant they'd get a greater flood of people than those who accept fewer or no insurances, but I still have a perception that it's almost impossible to find a psychotherapy-practicing psychologist around here who takes insurance . . . some of this is based on some comments made by my psychologist in my most recent session, I was so shocked by his views that he was trying to help me not have such high expectations of psychiatrists, that I even blurted out, "Dinah of the Shrink Rap blog I told you about would highly disagree with what you are saying!" Lol. Then again I also have heard there's kind of sometimes well there's a competitive, wary edginess between psychologists and psychiatrists sometimes since they can be in competition for people's business (at least the psychiatrists who practice psychotherapy are.)

Anyway, what I took from my therapist's comments about the state of psychiatry around here, is that in his experience with so many people he's treated, especially in recent years, that there just aren't enough psychiatrists to not do anything but shuttle people in and out for med checks . . . I didn't get the impression he was trying to promote negative stereotypes of med-management psychiatry, rather that my experience has shown that some med-check psychiatrists can be rushed, that it's an imperfect system, that it's been, in many ways, forced on the psychiatrists by the insurance companies . . .

I don't want people to think badly of my psychologist after what I just said above; I really had the impression he was just trying to help me feel less negative about my psychiatric experiences, to "normalize" them as having alot in common with what he generally hears (not that he told me about other clients, but he did say in his experience). It didn't come across as a put-down, just as the reality of what I and others have experienced.

Sorry to go on! Anyway I feel psychiatry is sometimes limited by the "psychiatric culture" and by this I mean, again, the whole proximity to a major medical university, the population density of psychiatrists to the patient population, and maybe a few other things.

Dinah said...

Sarebear: Hmmm, sometimes I do think our readers have overly high expectations of psychiatrists/ doctors/ the health care system in general. I suppose it depends on the precise issue. In general, I think people are the most productive if they have high expectations of themselves, and happier if they have low expectations of others: it minimizes disappointment and allows for an occasional pleasant surprise.

I don't know any psychiatrists who practice psychotherapy and take insurance. I don't know how that would be financially feasible, both from the perspective of income, and from the hassle factor of wrangling with insurance companies for reimbursement.

Thanks for referencing me. I feel famous being talked about in Utah!

Anonymous said...

It does help to maintain low expectations of others. To date, no one has failed to live up to my low expectations, sometimes they have even gone so far as to surprise me and then, lesson learned I adjust my expectations lower still. Shrink do a job. Like anyone else in any other job, some are better than others at what they do. It is probably reasonable to assume that most are okay, a few are awful and a few are great at what they do. Most live lives not so unlike their patients; they deal with the stuff of life either well or not so well. Some have major problems that are not controlled and should not be practicing. A very few have deep, deep insight into LIFE. Most should not be dispensing advice on how to live life or what to do with a problem in life since they have not figured out their own yet. One of the biggest limits is that too many cannot see the limits of psychiatry or of themselves as doctors, never mind human beings.
This question is similar to what are the limits of mechanics. Some light keeps going on in my vehicle. I bring it in every so often, they tell me they are not sure what it is but that I could use an oil change or a cabin air filter or a tire rotation or a tie rod. I leave with a lighter wallet and they turn the light off for me but tell me they expect it will come back still no idea why but do bring it in when it does. I drive for three days and sure enough it is back on. They have a hundred plaques on the wall certifying them as experts in this and that service, still the light stays on. Psychiatrists are mechanics with cleaner fingernails.

Dinah said...

The true irony of the last comment, by the anon who pointed out how shrinks are struggling with same problems, is that I have that precise issue with my check engine light. Really weird.

jesse said...

To the last Anon: what you wrote is publishable brilliant.

Anonymous said...

Thank you, Jesse. I have had a few pieces published, actually. Not so sure this was all that, but anyway, thank you. On first read of your comment, I read it as punishable! That is why I like to stay anon, to the extent that is ever possible on the internet.
Dinah, the light is probably related to the emissions sensor and strangely does not necessarily mean that either your car or mine is spewing anything more dangerous ,or in greater quantity, than cars without the same problem. In some way, I can identify with my car. It has been through some rough patches but you can't seem to kill the engine.