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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by pseudoname on July 2, 2006, at 8:39:40
I haven’t seen the book, but a review in Harvard Magazine of David Brendel’s new book "Healing Psychiatry: Bridging the Science/Humanism Divide" lays out four pragmatic principles to improve clinical psychiatry. He is head of psych residency at Mass Gen and McLean hospitals.
“The science is there, and we need to be able to apply the science, of course,” he says. “But we also need to be aware that the person we’re talking to may not fit into the schemas that we’re using at any particular time.” The field’s current scientific tools … do not adequately address the variable forms and causes of emotional and mental suffering.
Brendel says psychiatrists need to be…
• PRACTICAL – by focusing on good clinical outcomes for patients rather than on rigid application of “evidence-based” treatments,
• PLURALISTIC – by considering a wide range of treatment approaches,
• PROVISIONAL – by not taking any “evidence” too seriously because it is likely to change with further study and clinical experience, and
• PARTICIPATORY – by co-constructing treatment decisions with the patient.He also says that even in a hundred years, psychiatry will not have clear-cut diagnoses, no matter how much we learn about neurology or genetics.
(Review at http://www.harvardmagazine.com/on-line/070647.html Jul-Aug ’06, with a longer article on psychiatric diagnosis.)
Posted by iforgotmypassword on July 2, 2006, at 11:34:07
In reply to the 4 Ps of psychiatry?, posted by pseudoname on July 2, 2006, at 8:39:40
well, i am not being treated because i have no clear cut diagnosis. oh, other than about 7 personality disorders on my file.
how do i find doctors that actually go by this philosophy. my life is practically gone and my youth was erased by doctor's shrugging their shoulders and saying "see ya".
Posted by pseudoname on July 2, 2006, at 11:53:48
In reply to Re: the 4 Ps of psychiatry?, posted by iforgotmypassword on July 2, 2006, at 11:34:07
> how do i find doctors that actually go by this philosophy.
I wish I knew. Unless you live near Boston, I mean. Do the Mass Gen & McLean residencies post where their grads go?? Anybody know?
Patients can also adopt some of those Ps, I think. Like being practical, pluralistic, and provisional. Lowering one's expectations, temporarily making-do with limited relief, and applying any other therapies as much as possible (which may not be much but can always be done to some extent).
I think pdockery should always (?) target discrete symptoms rather hunt for than all-encompassing diagnostic syndromes. I think eventually pdocs will realize that, too. That's why I disagree with Brendel that diagnosis in 100 years will be as wishy-washy as it is now.
I sure wish you better luck with practitioners, ifmpw.
Posted by llrrrpp on July 2, 2006, at 13:10:31
In reply to finding 4-P pdocs » iforgotmypassword, posted by pseudoname on July 2, 2006, at 11:53:48
> > how do i find doctors that actually go by this philosophy.
>
> Patients can also adopt some of those Ps, I think. Like being practical, pluralistic, and provisional. Lowering one's expectations, temporarily making-do with limited relief, and applying any other therapies as much as possible (which may not be much but can always be done to some extent).
>
> I think pdockery should always (?) target discrete symptoms rather hunt for than all-encompassing diagnostic syndromes.Hi Pseudo,
perhaps one can find doctors based on the stuff they write. For instance, if you want a pdoc who is aware of these 4 p -s why not start with the author, or the doctors cited in the article?I guess I'm lucky, because my T did the reading for me and made a very good recommendation for a pdoc. At the time I was not capable of making a good decision. I couldn't even manage to feed myself, much less read scholarly articles and do research on pdoc's therapeutic models.
One other thing I think is that it's important to take clusters of symptoms into account. For instance, anxiety in the presence of methamphetamine abuse should probably be treated differently than anxiety in the presence of Cushing's disease, depression, cancer, etc.
I suggest this, especially since the current therapies do not (usually) target just one symptom. The drugs are dirty, and anxiety symptoms can be affected through any number of different hormone and neurotransmitter manipulations.
I'm not sure if I interpreted you correctly when you suggest that "pdocery should always (?) target discrete symptoms..." If I've taken your words out of context, I apologize.
-ll
Posted by Phillipa on July 2, 2006, at 13:17:39
In reply to Re: finding 4-P pdocs » pseudoname, posted by llrrrpp on July 2, 2006, at 13:10:31
Well I don't have to worry as I won't be here l00 years from now. But what about the Spect Scans and stuff like that? Love Phillipa
Posted by iforgotmypassword on July 2, 2006, at 13:37:47
In reply to Re: finding 4-P pdocs, posted by Phillipa on July 2, 2006, at 13:17:39
> But what about the Spect Scans and stuff like that? Love Phillipa
Boycotted by the insurance companies, drug companies that would lose their monopoly over the idea of what a new innovative drug is, and doctors who don't want to have rewrite the DSM they rely on for sifting through patients at their own convenience, and more importantly, they don't want to be told that they have more that they need to learn.
Posted by Jost on July 2, 2006, at 14:37:35
In reply to Re: finding 4-P pdocs » Phillipa, posted by iforgotmypassword on July 2, 2006, at 13:37:47
Not all pdocs are like that. Lots are, but if you keep on trying, you will find one. It's much harder than it should be.
My pdoc, for example, said they won't know for 500, not 100, years-- so he tries to adapt to the meager information he has-- and how meds work for his patients, or don't.
Reading, or even calling and asking for referrals, if you find a pdoc you like--which may not work, they don't necessarily know people in different cities-- is one way. But also looking through medline or psychoinfo, until you find an article that resonates with you, and who lives near you might also be a way.
Psychinfo used to be an online collection of articles in the area of psychology. Probably still exists. I get access through a university library database. But there probably are others way-- Public library might have it, or know how to get it.
Jost
Posted by pseudoname on July 2, 2006, at 16:39:33
In reply to Re: finding 4-P pdocs » pseudoname, posted by llrrrpp on July 2, 2006, at 13:10:31
Hiya, ll!
I guess I'm thinking of where I'd like to see psychiatry go over the next 100 years. I doubt that many of the diagnoses we are currently offered as unitary biological conditions actually exist that way. I suspect that depression, bipolar, schizophrenia are more varied than "infection" or "cancer".
I'm willing to concede that others better understand how useful the diagnoses are. Maybe I'm just talking out of my nose. But my impression is that they do not help in any situation more than considering the individual symptoms would AND (I think) they are more likely to be counterproductive.
> One other thing I think is that it's important to take clusters of symptoms into account.
Symptoms do cluster, but statistically in a population, not determinatively in an individual. If I have 5 out of 8 symptoms in a known cluster, I'm no more likely to get one specific remaining symptom than anyone else is. (Somebody please correct me if I misunderstand that.)
If I have some depressive symptoms but not others and anxiety about some social situations but not others, I don't think I'm in an identifiable subtype for treatment or physiology or prognosis. If not, what are we doing with these many clusters? Researchers can use them, but clinicians?
> For instance, anxiety in the presence of methamphetamine abuse should probably be treated differently than anxiety in the presence of Cushing's disease, depression, cancer, etc.
Yes; good point! But while symptoms don't occur in a vacuum, I don't think the DSM clusters or categories help at all in the treatment. The DSM just keeps expanding the classifications and subtypes to the point where it would as it approaches infinity have a category for every single situation. Ballooning toward a defacto symptomatic approach. Maybe I'm wrong.
I imagine a pdoc of a more desirable future saying, "We can remove your anxieties this way, but that may increase your cynicism that way; or we can reduce some anxieties this other way and leave room for improving your feelings of connection to others."
> I suggest this, especially since the current therapies do not (usually) target just one symptom. The drugs are dirty
Yeah, that's very true. I'm hoping things will change as the technologies get better. Then again, in the 1980s I thought we'd be there now. For now, I don't think the drugs target diagnostic clusters very well, either.
> I'm not sure if I interpreted you correctly when you suggest that "pdocery should always (?) target discrete symptoms..."
I guess I want pdocs to think more freely about the unique details of the individuals in front of them. I think that the DSM clusters and these overarching, vague diagnostic categories don't differentiate treatments any more than the symptoms considered individually would. Instead, current diagnoses produce LABELS that are more likely to mislead and obscure than understand and help the wild-type humans. ;-)
Just my bile, maybe. Thanks for dialogin'.
Posted by llrrrpp on July 2, 2006, at 17:44:38
In reply to symptoms and clusters » llrrrpp, posted by pseudoname on July 2, 2006, at 16:39:33
Hi Pseudo,
you're most welcome for dialoging. Apologies for being unclear. My brain is pretty fuzzy today. *yawn*Human minds are adapted to use categories in their reasoning. It allows us to use a little bit of data to make a lot of predictions. For example, show me a photograph of a cat, and I can predict that the cat likes to eat fish, was not hatched from an egg, and is not a happy swimmer. This is because I have a schema of "cat" that allows me to draw a lot of generalizations about any individual cat based on what I know about the category "cat" as a whole. [nevermind that *my* cat prefers muffins over salmon...]
Similarly, my pdoc looks at me, an individual, complaining of x,y, and z. Asks me a few more questions, asks me if there's anything relevant that he should know about (I never know what I should mention here- depression pretty much affected most of my body's systems and most of my social interactions). Pdoc asks me about my family history- again, what's relevant? Grandpa's alcoholism? Father's explosive temper? My sweet great-grandmother who lived until her late 90's with no dementia?
Like most instances of human reasoning, practitioners use categories to make the most efficient use of limited data. The problem may be in the nature of using DSM criteria as rigid categories, rather than examining natural variation along a continuum. It's important for practictioners in various mental health endeavors to have a common vocabulary, so that when an individual has "anorexia" on his or her chart, a new pdoc can come into the scene, read the chart, and know how to structure an interview with a new patient. It's fascinating that what we call major depression has been characterized as melancholia even in ancient times, with similar discription of symptoms. Likewise it's fascinating that acute psychosis has been associated with the affected individual acting under the power of demons. The demons may be specific to China, or Salem Mass., or Western Europe, but the gross descriptions are remarkably consistent.
As a fellow wild-type human :) I derive some comfort in knowing that the symptoms I experience have been experienced before. That there's a name for it, and a drug that is approved to treat it. At this point my comfort evaporates. I ask my pdoc what's the matter with me? Pdoc says that it's probably an interaction between my genetic material and my current and past environment. That the current ways of diagnosing individuals doesn't really help pdocs decide which drugs will work best for which individuals. Brain imaging techniques can suggest that certain individuals have abnormal activity or structure, but do not specify how that abnormality came to be. Furthermore, presence of biological markers currently does not provide better indication differential response to treatment than a clinical interview, in many cases for many disorders.
In the meanwhile, I am happy that my pdoc considers my insomnia in light of the fact that I also have anhedonia, apathy, sadness, etc. We each get to do our own experiments, sample size of one. Treatment effects often difficult to distinguish from placebo effects, many uncontrolled confounding variables (Was it the increase in AD dosage, or the approach my T used with me this week? The fact that there is more daylight than last month, The fact that my workload has increased? -- what's the cause? what's the effect?). We also have to expect that a treatment that worked in the past may not affect us the same way in the future. I hope that everyone's pdoc recognizes the individuality and subjective experiences of their patients.
I already think we've come a long way in considering the entire biology of an individual, which includes their brains, and their minds; rather than treating their "mental symptoms" and their "physical side-effects" [and vice-versa] as 2 completely separate systems contained within an "individual"
*yawn* my physical weakness and my mental sleepiness suggest that I need to take a nap.
ciao pseudo,
-ll
Posted by capricorn on July 3, 2006, at 0:09:43
In reply to symptoms and clusters » llrrrpp, posted by pseudoname on July 2, 2006, at 16:39:33
Blame it on Kraepelin ;)
Let's do the 'dimensional'
Posted by pseudoname on July 4, 2006, at 12:57:01
In reply to Re: symptoms and clusters » pseudoname, posted by llrrrpp on July 2, 2006, at 17:44:38
What a great exchange. When I really have to think about a topic, I spend more time writing a single post than I did writing some college papers. (Which is good. In my current life, most of the few people I see are too polite or uninterested to challenge me about anything.)
I would not expect anyone to read this; it's just so long. But I got a lot out of writing it, so thanks for that opportunity.
> Human minds are adapted to use categories in their reasoning.
Like race and ethnicity? Arguing from evolution can be dicey. A lot of (most?) research-level mathematical / statistical data collection, reasoning, and experimental designs are non- and even counter-intuitive. Those aren't the circumstances our brains evolved to work in. I think the better lesson from evolution is that we should be aware of our previously adaptive predilection for categories and guard against further categorizing without evidence of IMPROVED predictions.
And that's what I'm saying: current official diagnoses in psych do not give better predictions than does considering the individual symptoms WITHOUT further labeling of the patient. In fact, if the labels are taken seriously, they can get in the way and do harm. Maybe that's because human minds evolved to embrace categories so eagerly. If the categories are unnatural and misleadingly gathered together, then the pdoc who follows them is blinded.
Someone could say, "Well, get better categories!" Okay, I'll let them work on that. Meanwhile, we need to protect ourselves against our stone-age hunger for easy labels. One way to do that, while still keeping at our fingertips all the controlled, scientific data we've produced, would be to set aside most of the psychiatric diagnostic labels, especially those ambitious, flexible umbrellas that try to bring together so many vague, variable, disparate observations under one catchy name.
The clinical scenario you described…
> Similarly, my pdoc looks at me, an individual, complaining of x,y, and z. Asks me a few more questions [etc]
…does not seem to me to be guided by diagnostic categories. A full history and raft of questions should be part of any psych evaluation. If the pdoc leaves any part of it out because she's following an official cluster, that's a BAD thing.
She may know that some symptoms often do cluster together, and that may lead her to look for more symptoms in that cluster. But that in itself can introduce a lot of bias, cueing the patient to "find" the doc's eagerly anticipated symptoms and falsely confirm the doc's suspicion. I've been a victim of that more than once, and in fact studies show that's what often happens.
<snip>
Tom Widiger, who served as head of research for the DSM-IV, points out, “There are lots of studies which show that clinicians diagnose most of their patients with one particular disorder and really don’t systematically assess for other disorders. They have a bias in reference to the disorder that they are especially interested in treating and believe that most of their patients have.” Unfortunately, because psychiatry and its sister disciplines stand under the authoritative banner of science, consumers are often reluctant to challenge the labels they are given. (Jan 3 '05 New Yorker)
<snip>That would be reduced by skipping "diagnoses" and focusing on symptoms only.
The bias described may not be as much of a risk for a GP looking at abdominal pain. I think the key difference is in our current level of technology for examining and psych conditions, which is simply not analogous to examination technology in (other) medical conditions. Most psych evaluations are made almost entirely on the basis of the patient's report of amorphous, somewhat vague, varying, variably salient, and highly selected symptoms that are notoriously difficult for the patient both to observe without bias and to communicate freely. Physical medicine, even in ancient times, has never dealt with that level of obscurity and subjectivity.
But all pdocs get most of their training in medical clinics and ERs. They then expect that if psychiatry is a legitimate part of medicine, it must have similar diagnostic decision trees and use them with similar confidence. That confidence is not supported by evidence.
Even if a pdoc uses the clusters that we know exist statistically in the population to guide her questioning of a patient and she uncovers more good information, that's a long way from giving that patient a differential *diagnosis* to take home based on a partial match to some statistical cluster.
> Like most instances of human reasoning, practitioners use categories to make the most efficient use of limited data.
The efficiency seems to me to be beside the point. If the examination is narrowed before adequate data is collected or if the conclusions are misleading, these diagnostic categories potentially waste YEARS. The difference is of course that the wasted time is the patient's, not the doctor's.
> The problem may be in the nature of using DSM criteria as rigid categories, rather than examining natural variation along a continuum.
Hmm. I believe "rigid categories" are usually known as "categories." ;-) If the point of this new distinction is that we should treat psych patients based simply on their individual symptoms, then I agree.
> It's important for practitioners in various mental health endeavors to have a common vocabulary
There's a working common vocabulary already or no one would be able to go through those checklists of SYMPTOMS — which I would say are the common vocabulary. And the DSM diagnoses are hardly "common" since good reliability has never been demonstrated for any of the editions. And when only any 4 of 8 different symptoms qualify a patient for Diagnosis X, you and I could have no symptoms in common yet both have the same named disease! That's not a helpful shared vocabulary, either.
One could say, well, the practitioner will look at the actual list of reported symptoms for each of us. YES! That's my point!
> when an individual has "anorexia" on his or her chart, a new pdoc can come into the scene, read the chart, and know how to structure an interview with a new patient.
By asking her about the details of her actual symptoms, I'd hope.
What if anorexia is just one part of a larger, crazier, very unwieldy experience? What if (Is such a thing even possible?) the original label is WRONG? In any case, if the pdoc structures very much at all on the basis of one label pasted by someone else onto this enormously complex human, then the patient is at risk.
If the patient refuses to eat, then address that clinically. The chart description would be obvious and further characterization of it superfluous. I'm immediately on alert to any pre-emptive "structure". What might it leave out? What does it so surreptitiously bring in?
> As a fellow wild-type human :) I derive some comfort in knowing that the symptoms I experience have been experienced before. That there's a name for it
Yeah. Quite a few people have talked about the relief they've immediately felt on getting a diagnosis. I remember it myself. But would that be so different than a pdoc saying, "Your sleeplessness, irritability, anhedonia, [whatever], have all been experienced by others before, in various combinations, and are all due to the interaction of your genes and history and environment. We can treat some of these problems this way and give you skills to deal with these others that way [or whatever]"?
If patients feel alone and freakish and hopeless in their problems, then those are things that should be dealt with directly and explicitly, in an individual way tailored to the patient's own experience. Right? Or do we need another DSM number for people who feel freakish and hopeless and get relief on hearing a diagnosis?
The relief people initially feel on getting a diagnosis is very real, I know. But utterly FAKE, random diagnoses (well, psychological insights) have been given to people who immediately report relief on hearing them. Horoscopes also give this relief. But that benefit is NOT the purpose of a diagnosis. If the relief is called for, then the providers should address that issue directly.
I also think that such initial diagnostic relief is outweighed by the multitude of long-term problems that official psychiatric labels can give people.
> I hope that everyone's pdoc recognizes the individuality and subjective experiences of their patients.
I think that will be easier to bring about if we rely less on the volumes of proliferating diagnostic entities and more on simply treating the unique details that present in each patient.
> We each get to do our own experiments, sample size of one.
That's a great way to put it.
I have imposed too much on Bob's bandwidth and your time. Thanks to anyone who read this.
:-)
This is the end of the thread.
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