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Is Your Psychiatrist Paying Attention

In my post of 2/24/2010, Counting Symptoms that Don't Count, I discussed how many psychiatrists these days are taking huge shortcuts in order to squeeze as many patients into an hour as they possibly can. I described how they are focusing just on symptom counts without trying making the slightest effort to ascertain whether or not the symptoms in question are clinically significant for a particular diagnosis, or whether they might require psychotherapy rather than drug treatment.

As I have pointed out many times in this blog, in order to make such a determination, the doctor has to take into account the timing, pervasiveness, persistance, and subjective quality of a symptom. The psychiatrist has to know what other symptoms are present at the same time and at different times. Most importantly, the doctor has to know something about the psychosocial context of a symptom.

One of my partners reported a particular glaring example of what can happen when this is not done: A patient with no previous psychiatric history became depressed right after finding her husband in bed with another woman.  Her "depression" was characterized, not surprisingly, mostly by anger and preoccupation with the discovered affair.  Nevertheless, when she came to the attention of a psychiatrist, he diagnosed her with "major depressive disorder."  Really?  I mean, really???

Another time saving "convenience" is for the doctor to write down the information that the patient is relaying during an interview on the patient's chart, using either pen and paper or a computer, as the patients speaks. This not only saves time, but solves a second problem: Some insurance companies do not want to pay for a doctor's time unless it is spent face to face with the patient. Even time spend reviewing the patient's record and writing down all the information that insurance companies demand in order to pay the doctor is supposed to be donated, I guess. So instead of writing a progress note after the patient leaves, it is written with the patient still in the room!

So, aside from wasting the patient's time while the doctor does that, what's wrong with that?

Well, I'll tell you.  When a doctor is writing or typing away on a computer, his or her attention is split between doing that and observing the patient. Often a patient's body language or facial expression can give a doctor a clue that what the patient is saying may not be completely accurate or may not be the whole story, so that the doctor then needs to ask for clarification with follow-up questions. When the doctor is staring at a chart instead of the patient, that is probably just not going to happen.

Even more important, patients will often mutter vitally important information quickly and in passing, or even under their breath. This is particularly likely to happen if the information patients are relaying is troublesome to them in one way or another, such as reporting things they are ashamed of. If the doctor is not paying close attention, he or she will literally not hear it!

In my book, How Dysfunctional Families Spur Mental Disorders, I describe in detail a videotape of a psychiatry trainee doing a diagnostic interview in front of two senior faculty members in order to practice for her upcoming oral boards. In the videotape, a real patient was used. During the interview, the patient stated in passing that she had been repeatedly molested by a close relative. In fact, the matter even ended up in court. After the interview, the examiners both said that they "suspected" that a trauma history was "likely" in the patient.

There were three doctors in the room, all of them preoccupied with the trainee's performance.  All three of them either missed or forgot that abuse was not only likely, but had actually been mentioned!

Is consumer culture making us anxious and depressed

According to one recent ABC News story, yes, it is:

Margit Burmeister, professor of psychiatry and human genetics at the University of Michigan, said it "makes very good sense with what we know of lifestyle changes in the past 50 years" that our consumer culture is affecting mental illness.

She added that "genetic vulnerability [to mental illness] is the other side of the coin that needs to be kept in mind" -- in other words, as our society piles more and more stress onto its citizens, those who are predisposed to crack under the pressure, will...

Dr. Bruce Rabin, medical director of the Health Lifestyle Program at the University of Pittsburgh Medical Center, said that beyond our society's focus on external goals, the stress level among parents in recent times has impacted the type of children we raise.

Children today "lack meaningful, healthy role models," Rabin said.

"They learn from those they love...if role models are short tempered [or] tell children to leave them alone because they are under a lot of stress...there will be an effect on the child's mental health development."

In this way, he said, children learn which aspects of life to make a priority. Relationships take a back seat, and work, success, material gains take precedence.

Lots of statistics speak to the validity of this opinion. There's no question that society is more atomized than it used to be -- that people are more geographically mobile, hold more jobs during their working years, work longer hours but are less likely to make enough money to be able afford to buy a house, and are less likely than they used to be to be part of a strong community. (See the book Bowling Alone for as many statistics along these lines as anyone will ever need.) Thanks to the growth of corporate America, there are more and more cookie-cutter office parks and shopping centers than ever, and fewer and fewer places that are culturally unique or untouched by commercialism. (Thank you, Starbucks.) Television, the internet, and the advertising and public relations industries saturate our lives with images of "the good life" while pushing on us an endless parade of products we don't really need. (Spend some time with the most recent SkyMall catalog if you don't know what I'm talking about.) A society that used to treasure privacy now produces more than a few citizens whose primary life goal is seemingly to land a spot on reality television. (E.g., the attention-whore couple who recently attended a White House function without an invitation.) It's no surprise that recent decades have brought alarming mental illness growth rates.

So what's to do? According to the article, "If increased materialism and decreased community are really to blame -- at least in part -- for this trend ... then interventions may have to be taken at the societal level."

In other words, we're screwed.

All Food Is Poison and Anything You Eat May Kill You

People with panic and anxiety disorder are very suggestible, and they are especially suggestible to their own stupidity. The story of the last month, below, reveals my extremely scientific approach to food intolerance and how it may affect the brain. Please note: If you read this and decide that you, too, are intolerant to all the things I have listed, then we should have a martini together. Contact me. (Except that martinis are derived from wheat, and are now a terrible poison to me. I will be drinking a tea made out of organic quinoa shavings, while you enjoy your delicious martini.)

About one month ago, I decided I was intolerant to Gluten. Gluten can cause all sorts of bad things, I’d read, and I wanted no part of it. It has been reported to cause indigestion, osteoporosis, rashes, and depression. I cut all Gluten out of my life. By the second day off Gluten, I decided I was cured of every anxious thought I have ever had. I ran about through the wet grass in the night, and hurled a tennis ball at the moon.

“Yah! I am cured!” I said to the moon.

A few days later I started feeling dizzy and anxious again, so I decided I had an intestinal parasite. I researched all kinds of parasites, and found out that some can bore into one’s brain! They really can. They can invade every major organ in the body. I researched some online cures that promised to expunge parasites from the body.

But what if it wasn’t a parasite? What if it was just my own idiocy? Then I would have paid $47 for a revolting “colon cleanse” that would just cleanse the nutrients from my body and make me even more dizzy and ill.

I held off, but still brooded heavily about the parasites.

Another week or two went by. By Thursday 5/19, I decided that I didn’t drink enough water. Water, by God, now that was the solution! If I could gurgle down about 10 glasses a day of water, I would be instantly healed and would wake up with my hair in a braid and a song on my lips. As I woke, I would sing a song that would begin with the words: “Another glorious day to celebrate my life!” I made a chart and started to check off how many glasses of water I imbibed per day. On the first day, I drank 10 glasses of clean, pure water.

I woke up feeling just as rotten as ever. “Perhaps,” I thought, “I was right about the parasites.” I also pondered a bit about brain tumors and incurable mental illness. Or maybe I had lactose intolerance? Maybe I was allergic to coffee. Maybe there was some kind of oil in the coffee bean that was sick-making, and caused incurable mental illness. Why, look at the proliferation of coffee shops, and all the poor sad addicts standing in line.

On Friday 5/20, I gave up coffee.


On Saturday 5/21, I was fully convinced that my troubles were all due to a mysterious malady called Fructose Malabsorption. If you have this problem, you can’t eat most fruits, high fructose corn syrup, asparagus, artichokes, onions, leeks, wheat, and brown rice. Basically, everything that is good for you. Fructose Malabsorption can make one extremely anxious and depressed, and can even make one’s eyeballs ache. Plus, it causes bad poop incidents and a bloated tummy that looks like you just swallowed a dodgeball. All these terrible things have happened to me. Therefore, I had "Fructmal."

I started drinking coffee again. What did it matter? Apples were poison.

By Sunday 5/22, I had discarded the Fructose Malabsorption theory altogether. It would be a bore to never eat an apple again! How would I explain this weird food intolerance at Appletini parties?

Instead, I now determined that my trouble was corn and dairy. Corn, the evil of America! No pretty corn-fed maidens, sipping frothy glasses of milk, would tempt me again. I packed up the industrial-sized bag of Costco tortilla chips and, on Monday 5/23, thrust them at our nanny on my way to work.

“Take them, take the awful things from my sight!” I begged.

“But, we just bought those,” she said.

“And look, I have eaten half the bag,” I cried. “It is no wonder the corn has made me quite ill and mad.”

I glared at the cheese in our fridge with suspicion. No doubt it had been made from mad cows and goats, and eating it would pickle my brain matter. I would eat no cheese. I gave up coffee again. I had some weak tea without sugar and milk. I felt very bitter.

By now there was very little left on the "safe list" that I could eat. I ate a few nuts and a banana for breakfast, and became worried about the Fructose thing all over again. “Suppose I was right, and this banana is not on the ‘safe” list, and it makes me sicker than ever!” I fretted about this on the way to work.

By 11:00 I was so weak and shaky from not eating a proper breakfast that I had a panic attack, and immediately nibbled at the corner of a small Xanax. I felt much better.

If you can cure me of this stupidity, I will send you a package of cookies. They will not contain any wheat, corn, dairy, nuts, fruit juices, or sugar, and will taste like little turds coated in sawdust.

Is Your Psychiatrist Committing Malpractice Even if Doing What a Lot of Other Psychiatrists Are Doing

My malpractice carrier, which is physician owned and operated, recommends taking one of their seminars or online courses on different aspects of medical malpractice every year, and gives those policy owners who do a 10% discount on their yearly premium. 

The course I took this year was on misdiagnosis.

The course was not really geared to psychiatrists at all, but it seemed to me that the general advice still applies to them. However,  in my experience the advice is not clearly being followed by a lot of my colleagues these days. If these recommendations are indeed valid, and I certainly agree that they are, a lot of psychiatrists are getting away with gross negligence. 

Statistics show, by the way, that doctors are actually far more likely to get sued for something they did not do wrong than they are to get sued for actual malpractice. Isn’t that bizarre?

Some of the advice in the malpractice course concerns two major criticisms of my colleagues that I have written about extensively on this blog and in my last book: relying on symptom checklists, and relying on a diagnoses made by a prior clinician. Truly frightening.

So, as a public service, here’s some information from the course that psychiatric patients might find useful if they are considering suing a psychiatrist for malpractice. From MedRisk (Medical Risk Management, Inc.).

Misdiagnoses were more likely to be considered negligent in malpractice suits. Misdiagnoses were more than three times more likely to result in serious patient injury than medication errors.

2.      Multiple case law decisions have consistently held that the patient has no duty to volunteer information the physician does not ask about, and the patient’s only duty is to answer the physician’s questions honestly. (A smoker actually has no duty to tell his cardiologist about the smoking if the cardiologist does not ask!)

3.      Review any written history questionnaires with the patient to make sure the information is accurate. Patients who are sick or in pain can’t be relied on to even read the questions carefully, let alone provide thoughtful answers. Many patients will simply respond with a “No” to all prior diseases without reading the list and some patients, as discussed below, may not even be able to read or understand the questions. For example, the patient with a known history of high blood pressure may answer “No” when asked if he has ever been diagnosed with hypertension simply because he doesn’t know that they are the same thing. So make sure that your questionnaires are worded as simply as possible. Even then, review the responses verbally with the patient and make sure that you really do have a useful medical history. 

      

      Most healthcare instructional materials provided to patients are written on a 10th grade reading level or higher. Yet the reading level of the average patient is 4.6 grade levels below the last year of school completed, which means that a typical high school graduate reads at around an 8th-grade level. Further, the average Medicaid recipient reads at less than a 6th grade level, with more than one-third reading below the 4th grade level.

4.      Hear the patient outwhile taking the history and do not interrupt. Physicians are often overworked, overbooked, and scrambling to stay on schedule. This can leave them anxious to get to the point of a patient visit. One study found that physicians on average interrupted patients only 18 seconds into the explanation of the reason for the visit. This is significant because patients typically have a list of several complaints or observations they would like to discuss, yet rarely get beyond the first or second before being interrupted. Cutting the patient off before you’ve heard him out is called “premature closure,” and the main problem with this approach is that it assumes that the presenting complaint carries the most medical significance.

This is often not the case because the patient experiencing multiple symptoms may not know which are the most important, nor which may be related to the same underlying cause. For example, the patient who reports transient blurriness in her right eye may not realize that the simultaneous tingling sensation she feels in her right arm and leg are related. Premature closure typically involves a patient with a serious but uncommon diagnosis who presents with symptoms suggestive of a less serious and more common diagnosis.  

Contributing to premature closure is a general human tendency to hear what we expect to hear, and mentally filter out as extraneous any details that we don’t expect. Fortunately, the main assumption underlying premature closure—that patients will talk endlessly if allowed—appears to be incorrect. Several studies have found that patients who are allowed to list all their concerns without interruption rarely speak for more than two minutes. Allowing the patient those two minutes not only prevents premature closure, but can actually save you time by allowing you to focus on the most important symptoms first. It also avoids those “Oh, by the way…” conversations in which the patient brings up a new problem just as you’re headed for the door.

And finally:

5.      Every doctor owes a duty of making an independent assessment of the patient, utilizing the full range of his or her clinical skills, regardless of whether you’re a primary care provider or a sub-specialty consultant. If you’re an FP [family practitioner] and receive a specialty ob-gyn report informing you that a 60-year-old woman who had a hysterectomy 15 years ago is pregnant, you’d obviously recognize that you’d received the wrong patient’s report or that some other mix-up had occurred. Yet far less blatant errors occur all the time in the exchange of patient information, and you should always be mindful of that possibility any time the specialist’s opinion doesn’t fit your clinical finding or the patient fails to respond to treatment as expected.

Clearly, the same can be said for not entirely relying on the diagnosis of some other practitioner even  in the same specialty, who may or may not have done a good diagnostic workup, but instead doing one’s own independent assessment. If a  psychiatrist prescribes something to you after initally talking to you for just fifteen or twenty minutes, find another doctor.

Autism is mind blindness

The young couple first approached a physician practicing in Indian system of medicine (Ayurveda) and then a Homeopath for the remedy of their only male child’s abnormality in behaviour. Both the Ayurvedic physician and the Homeopath assured the young couple a ‘complete cure’ from the curious malady of their son. But treatment which lasted for many months in both the systems failed and there was no relent in the devastating symptoms of the child. Finally they decided to seek the opinion of modern medicine and they approached a pediatrician who advised them to seek the help of a psychiatrist.

The young couple described the peculiarities of their son. Till the third birth day they did not notice any abnormality in the child. The first thing they noticed about their son is that he doesn’t like people to hold him or touch him. He often doesn’t respond when they call him. Even when they move their hand in front of his face he doesn’t respond. They had to pick him up to get his attention. His speech also is defective. The parents couldn’t often follow what he was saying. He repeats whatever he heard as echo but he doesn’t know the sense of many words he repeated. He could not follow their instructions like sit, come here, stand up etc. The most distressing behaviour was his avoiding of looking into their eyes. Evidently their son was suffering from autism. There was no medicine to cure the devastating disorder. Only special training, care and attention would improve the condition of the child. I explained the various aspects of autism to them.

Autism is a pervasive developmental disorder. It was discovered independently by two physicians, Leo Kanner in Baltimore and Hans Asperger in Vienna, in the 1940s. Both doctor had any knowledge of the other, and yet by a strange coincidence they gave the malady the same name: autism. The term was derived from the Greek autos which means self. They gave this name because the main feature of the disorder is confining to self withdrawing from the outside world.

The symptoms of the disorder can be categorized into two groups. The first group of symptoms pertains to the cognition of the child and its relationship with the outside world. Mental aloneness and lack of contact with the world, particularly the social world, as well as a profound inability to engage in normal conversation are the hallmark of this disorder. Going hand in hand with this is an absence of empathy for other which means a failure to understand others’ feelings and emotions. 

The second cluster of symptoms pertains to the sensory and muscular systems of the child. The autistic children find specific sensory stimuli highly distressing. Certain sound, for example, can set off a violent temper tantrum. There is also a fear of novelty and change and an obsessive insistence on sameness, routine, and monotony. The symptoms of motor system include to-and-fro rocking of the body, repetitive hand movements including flapping motions and self-slapping, and sometimes elaborate, and repetitive rituals. These symptoms are not quite as definitive or as devastating as the social-emotional ones, but they occur so frequently that must be connected somehow.

Mind Reading and Mind Blindness

Uta Frith

Uta Frith, leading developmental psychologist working at the Institute of Cognitive Neuroscience at University College, London put forward for the first time the cognitive theory of autism. She wrote: “Individuals with autistic disorder have occasionally commented on what they perceive as an unfathomable yet ubiquitous ability of other people to “mind read” during ordinary social interactions. Normal people indeed behave as if they have an implicit theory of mind, and this allows them to explain and predict others' behavior in terms of their presumed thoughts and feelings. To give an example: you might observe me in my office bent over a filing cabinet drawer pulling out and putting back folders. You would make sense of this behavior by mentalizing, that is, automatically recognizing that I am looking for a paper that I believe is in one of the folders and that I wish to retrieve. You would think this even if you knew that the paper was not there. To explain my behavior, it is immaterial whether the missing file is in the cabinet or really somewhere else. Suppose that you say to me “Try Debbie's desk,” and I respond with “I might have known.” Without mentalizing, this everyday exchange would seem like complete non sequiturs. Further, without mentalizing, you might come up with an outlandish interpretation of what I was doing—perhaps practicing back bending and finger moving? The important point of the example is that for an instantaneous interpretation of ordinary behavior, we automatically take account of the mental state of people, their desires, and their beliefs.” Neuron Vol. 32, no. 6, 12/20/01 pp 969-979. The difficulty in mind reading would result a condition called mind blindness which is main characteristic of autism.

Mirror neurons and mind reading

In the 1980s and 1990s, neuro scientists Giacomo Rizzolatti, Giuseppe Di Pellegrino, Luciano Fadiga, Leonardo Fogassi, and Vittorio Gallese working at the University of Pama, Italy discovered mirror neurons. They found that some of the neurons controlling the movements of muscles of hands responded when the monkey observed another monkey moving hands without moving its own hands. They called these neurons mirror neurons because they acted like mirroring other monkey’s actions. Further studies confirmed that about 10% of neurons in the lower parts of the frontal and parietal lobes of the monkey’s brain have “mirror” properties. A mirror neuron is the nerve cell that fires or becomes live both when an animal acts and when the animal observes the same action performed by another. Thus the neuron mirrors the behaviour of the other, as though the observer were itself acting. Such neurons were observed in various species of animals such as primates and bird.

V S Ramachandran

According the cognitive neuroscientist Vilayanur S Ramachandran, the mind reading ability derives from the mirror neurons situated in the various parts cerebral cortex. Ramachandran writes: “The clue comes from mirror neurons. In the late 1990 it occurred to my colleagues and me that these neurons provided precisely the candidate neural mechanism we were looking for. The discovery of mirror neurons was significant because they are essentially a network of mind-reading cells with the brain. We were struck by the fact that it is precisely these presume functions of mirror neurons—such as empathy, intention-reading, mimicry, pretend play, and language learning—that are dysfunctional in autism.”  The Tell Tale Brain pp 139,140