Psychiatrists & Patient Mental Disorder Diagnosis

Ned_led16

In the Edmond Stapleton case in Cork last week - there were differing opinions on Stapletons medical mental illness... Just looking at The Brevik case in Norway and they cant seem to agree on a diagnosis either:
My question is...surely there is a process to be followed in agreeing on a diagnosis??? Forgive me for saying.... but is it all a little Micky Mouse how Psychiatrists diagnose in Ireland???? Perhaps there is a better way? Seems odd how a Psychiatrist can get it so wrong bearing in mind the work involved in becoming one.

http://www.rte.ie/news/2012/0622/lawyer-says-breivik-should-be-declared-sane.html

http://www.rte.ie/news/2012/0622/man-guilty-of-cork-airport-charges.html

cranks

Ned_led16 wrote: »

In the Edmond Stapleton case in Cork last week - there were differing opinions on Stapletons medical mental illness... Just looking at The Brevik case in Norway and they cant seem to agree on a diagnosis either:
My question is...surely there is a process to be followed in agreeing on a diagnosis??? Forgive me for saying.... but is it all a little Micky Mouse how Psychiatrists diagnose in Ireland???? Perhaps there is a better way? Seems odd how a Psychiatrist can get it so wrong bearing in mind the work involved in becoming one.

http://www.rte.ie/news/2012/0622/lawyer-says-breivik-should-be-declared-sane.html

http://www.rte.ie/news/2012/0622/man-guilty-of-cork-airport-charges.html

A number of issues here.

You've highlighted the inherent difficulties often associated with psychiatric diagnosis.

Forgive me for saying.... but is it all a little Micky Mouse how Psychiatrists diagnose in Ireland????

It's not a phenomenon that is exclusively linked to psychiatric diagnostics in Ireland -as your two links highlight.

My question is...surely there is a process to be followed in agreeing on a diagnosis???

Yes, there surely is. The DSM-IV or ICD-10 provide checklists of symptoms, if you like, that are typically adjudged to have been met when a diagnosis is made. Both of these taxonomies are due for revision. The DSM process of revision has been a fraught one:
http://lawandbiosciences.wordpress.com/2009/09/10/the-politics-of-disease-definition-a-summer-of-dsm-v-controversy-in-review/ but that's another story.

Have a look at a typical Mental Status Examination (MSE) checklist which attempts to formalise the diagnostic process.

Checklists are all very well but that tells you nothing about the process of deciding if a symptom criteria is met. That's where the fun starts! because ultimately it comes down to qualitative judgements.

Consider the following:
http://en.wikipedia.org/wiki/Rosenhan_experiment

It makes for good reading and suggests that any of us could probably 'fake' mental illness but for the purpose of your post it does illustrate the fragile nature of psychiatric diagnostics. Aside from overt 'symptom' expression, close observation and consideration of the individual's broader context do need to be considered before arriving at a diagnosis.

Perhaps there is a better way?

Indeed. That prospect keeps most of us going.

JuliusCaesar

Can I remind everyone that psychiatry and psychology are not the same thing?

Psychiatry is a branch of medicine, and so your question is probably better off in the Health Sciences forum.

Valmont

Ned_led16 wrote: »

there were differing opinions on Stapletons medical mental illness... Just looking at The Brevik case in Norway and they cant seem to agree on a diagnosis either

The farce of the Breivik case should confirm what we know already: psychiatry (and perhaps the whole idea of 'mental illness' and its legal status) is a muddled pseudo-science. They can deliberate on his mental illness all day but they can't objectively confirm its existence in the same way they could confirm say, a peptic ulcer or leukemia.

Ned_led16 wrote:

Seems odd how a Psychiatrist can get it so wrong bearing in mind the work involved in becoming one.

They are the high priests of our time. And come to think of it, they also hold the legal monopoly on drug dealing.

JuliusCaesar wrote: »

Psychiatry is a branch of medicine

I'm aware of the distinction but it seems that clinical psychology and psychiatry cross wires in an important way: they both diagnose and treat mental illnesses. So are they not both a branch of medicine, one more than the other?

Debating psychiatry in the health sciences forum would be like debating Muhammed in the Islam forum. Can we have a haven for criticism here?

Odysseus

Valmont wrote: »

They are the high priests of our time. And come to think of it, they also hold the legal monopoly on drug dealing.

Would you mind expanding on that one Valmont.

Valmont

Odysseus wrote: »

Would you mind expanding on that one Valmont.

Psychiatrists use the words illness and disease metaphorically. They categorise certain personal, social, and moral problems as 'diseases' to be cured and treated, emulating how a doctor would diagnose and treat a peptic ulcer or cancer. Crucially however, in all fields of medicine excluding psychiatry, the illness or disease can be objectively identified, whether at post-mortem or some other stage. This is the traditional scientific-pathological approach to medicine promulgated by Rudolf Virchow -- psychiatry is unequivocally pseudo-scientific in that anyone can be said to have a mental illness of some form without any objective evidence demonstrating a physical lesion or pathological malfunction. (Of course, the traditional scientific formulation of illness and disease has been inflated to make room for mental illness, but that is another topic).

In short, social and moral issues formerly the remit of the priest have now been medicalised and incorporated into psychiatry under the guise of science. Just look at the expanding list of mental illnesses: oppositional-defiant disorder, sexual-addiction, gambling addiction, these are simply problem behaviours that are in a way swept under the rug by attributing them to a disease of the brain; which a few hundred years ago might have been explained as resulting from demonic possession or giving in to the devil or not adhering to the teachings of the bible.

Odysseus

Sorry mate, I meant the drug dealing reference.

Valmont

Odysseus wrote: »

Sorry mate, I meant the drug dealing reference.

They have a legal monopoly on the sale of psychoactive drugs which are often more dangerous than the illicit kind. There's not much to elaborate on with that one!

Odysseus

Valmont wrote: »

They have a legal monopoly on the sale of psychoactive drugs which are often more dangerous than the illicit kind. There's not much to elaborate on with that one!

See in my opinion there is, but I would rather hear your side before I mention the other side I'm aware. Sorry for the earlier mix up. totally my fualt.

Valmont

Odysseus wrote: »

See in my opinion there is, but I would rather hear your side before I mention the other side I'm aware. Sorry for the earlier mix up. totally my fualt.

Perhaps I should clarify: various persons involved in the mental health industry (psychiatrists, GPs, those prescribing methadone) have a legal monopoly over many but not all psychoactive drugs. Where else can I legally purchase xanax or valium or lithium? The control this institution has over the sale of these drugs meets the definition of a monopoly in my eyes.

Odysseus

Valmont wrote: »

Perhaps I should clarify: various persons involved in the mental health industry (psychiatrists, GPs, those prescribing methadone) have a legal monopoly over many but not all psychoactive drugs. Where else can I legally purchase xanax or valium or lithium? The control this institution has over the sale of these drugs meets the definition of a monopoly in my eyes.

Thanks for that, it's just I have come accross it in so many ways over the years I was interested in the point you where addressing it from. Sorry for the lack of clarity around my question.

cranks

Valmont wrote: »

Psychiatrists use the words illness and disease metaphorically. They categorise certain personal, social, and moral problems as 'diseases' to be cured and treated, emulating how a doctor would diagnose and treat a peptic ulcer or cancer. Crucially however, in all fields of medicine excluding psychiatry, the illness or disease can be objectively identified, whether at post-mortem or some other stage. This is the traditional scientific-pathological approach to medicine promulgated by Rudolf Virchow -- psychiatry is unequivocally pseudo-scientific in that anyone can be said to have a mental illness of some form without any objective evidence demonstrating a physical lesion or pathological malfunction. (Of course, the traditional scientific formulation of illness and disease has been inflated to make room for mental illness, but that is another topic).

In short, social and moral issues formerly the remit of the priest have now been medicalised and incorporated into psychiatry under the guise of science. Just look at the expanding list of mental illnesses: oppositional-defiant disorder, sexual-addiction, gambling addiction, these are simply problem behaviours that are in a way swept under the rug by attributing them to a disease of the brain; which a few hundred years ago might have been explained as resulting from demonic possession or giving in to the devil or not adhering to the teachings of the bible.

psychiatry is unequivocally pseudo-scientific in that anyone can be said to have a mental illness of some form without any objective evidence demonstrating a physical lesion or pathological malfunction.

Good point but I'm not entirely sure if you're arguing that there is no such thing as mental illness or that diagnoses are fundamentally unsound constructs.

I'd be curious to know what your view is of the diagnosis of autism (a differential diagnosis is childhood psychosis) or Asperger's syndrome (differential: schizophrenia)? Both contained i the DSM-IV alongside all those other disorders/illnesses whose validity as diagnoses you seem skeptical about. Yes, there have been many false dawns with autistic spectrum disorders with respect to genetic markers, organic/brain substrates identified by fMRI, etc but there is still no definitive test to demonstrate a physical lesion or pathological malfunction that I know of. Which brings us back to the good old DSM-IV and a subjectively made clinical judgement call based on as much objective information that it is possible to discern.

'Classic' autism is a relatively easy call to make as there is no doubt whatsoever that 'something is not right'. Sometimes however its constellation of symptoms is a little more subtle and harder to identify and make qualitative judgements, based on a quite involved clinical assessment, trickier.

The same line of reasoning applies to those other diagnoses that require qualitative judgements (i.e. psychiatric diagnoses). Hallucinations are a good example - sometimes it's abundantly clear that 'something is not right' (both to the clinician and the sufferer, I might add) but sometimes it's very subtle. Unless you've been present with someone in the throes of terror due to the ongoing experience of loud, command hallucinations, (no test/biological marker for this) and seen the relief that these toxic psychiatric pharmaceuticals bring, it is perhaps easy to be critical of the psychiatric diagnostic process and expound the pseudo-science argument.

I should add that I'm not a psychiatrist nor an apologist for psychiatry. I concur with your concern around the expansion of diagnoses. We might be in for a whole bunch more in the not too distant future! However, I frequently refer to the DSM in its current guise in my work and am called upon to apply labels as per this taxonomy (see above). In my experience, clinicians do not make diagnoses (apply labels) lightly.

Odysseus

Valmont, have you read Discipline and punish, and the birth of the clinic or even Madness and Civilisation? Sometime it seeems you are influenced by T Szazz are you? I use him with students to get them thinking if don't I don't agree with it. What are you thoughts on him?

Ned_led16

JuliusCaesar wrote: »

Can I remind everyone that psychiatry and psychology are not the same thing?

Psychiatry is a branch of medicine, and so your question is probably better off in the Health Sciences forum.

I disagree! I put it to you that this is the correct forum as Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptual abormalities.

Anything is a branch of another in some way. Thats a bit of push back! i think when discussing Psychaitric treatment and diagnosis that it is entirely appropriate for this forum - as u can see the wealth of information provided in the responses. I dont think there would be such knowledgeable to the point response in health science but more than willing to try if you like?

Psychology is the study of the mind, occurring partly via the study of behavior.[1][2] Grounded in scientific method,[1][2] psychology has the immediate goal of understanding individuals and groups by both establishing general principles and researching specific cases.

I know a person who i think is bipolar but hasnt been diagnosed. But i think if you were to diagnose him it would be impossible unless you interviewed him once a week for 2 yrs. Saying that he hasnt had any really crazy manic episodes i know about since his doctor has been prescribing him with valium and god knows what else... But another topic and question is - should a doctor be able to prescribe drugs?? or should it be Psychiatrists only... there is a street trade now where people on the dole get as many prescriptions as possible and sell the drugs on to pay for other illegal drugs - the pharmaceutical companies are loving it but the tax payer is paying a fortune for it - i think some people on the dole are getting upto 150 euro a week of prescription drugs when they dont need them... this worries me more in the sense that i dont think Doctors are qualified enough to prescribe for mental health... surely it should be someone who is a mental health specialist such as a psychiatrist... ramble ramble ramble!!! im sure of i went to my doc with no mental health issues i could get almost anything!

JuliusCaesar

Valmont wrote: »

Debating psychiatry in the health sciences forum would be like debating Muhammed in the Islam forum. Can we have a haven for criticism here?

Or maybe it's like debating Islam in the Atheism forum?

Ned_led16 wrote: »

I disagree! I put it to you that this is the correct forum as Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive perceptual abormalities.

Anything is a branch of another in some way.

The fact remains that psychiatrists are medical doctors who have specialised in psychiatry, just as oncologists are medical doctors who have specialised in cancers, or anaesthetists are doctors who've specialised in anaesthetics.

LostPassword

Valmont wrote: »

Crucially however, in all fields of medicine excluding psychiatry, the illness or disease can be objectively identified, whether at post-mortem or some other stage. This is the traditional scientific-pathological approach to medicine promulgated by Rudolf Virchow -- psychiatry is unequivocally pseudo-scientific in that anyone can be said to have a mental illness of some form without any objective evidence demonstrating a physical lesion or pathological malfunction.

Nonsense. Many, many, many forms of ill health that are routinely addressed outside of psychiatry are identified by subjective judgement - pain being the most obvious, but there are many others, migraines being one common example. And, the perceptions of a patient are themselves a piece of objective evidence from the point of view of the doctor and they are virtually always present as a precondition for a patient seeing a psychiatrist - how many people present to psychiatrists who do not perceive themselves to be suffering from reasonably intense psychological distress?

The job of psychiatrists is to evaluate their patients' perceptions of distress in order to categorise them into one of a reasonably large number of categories which represent the most common patterns of presenting patients. Just because this relies upon subjective evaluation of patient perceptions and cognitive functions does not make it pseudo-scientific, it just makes it error prone, inexact and subject to a whole heap of cognitive biases of the practitioner - but any decent psychiatrist worth his or her salt understands this.

Valmont

LostPassword wrote: »

Nonsense. Many, many, many forms of ill health that are routinely addressed outside of psychiatry are identified by subjective judgement - pain being the most obvious, but there are many others, migraines being one common example. And, the perceptions of a patient are themselves a piece of objective evidence from the point of view of the doctor and they are virtually always present as a precondition for a patient seeing a psychiatrist - how many people present to psychiatrists who do not perceive themselves to be suffering from reasonably intense psychological distress?

I think you have misunderstood me. I'm not denying mental anguish or the importance of patient reports but your own example demonstrates the pseudo-scientific nature of psychiatry. A patient presenting with a complaint of a headache will be given some painkillers -- he won't be given a diagnoses unless the pains persist and he is referred to a neurologist. Now, this part is crucial:

Psychiatry is the only medical field where the practitioner cannot tell a patient they do not have a disease or illness. With the headaches or migraines, a neurologist can objectively confirm the presence or absence of a pathology. With the psychiatrists, all they have to go on is the patient's report, so if they patient keeps telling them they have symptom x, hey presto, they have a brain disease. No actual objective evidence needed -- so if psychiatry is a medical science, like neurology, why does it get special treatment?

I can tell my GP and specialist over and over again that I have pains in my appendix and think I have appendicitis. They can perform scientific tests to conclusively determine whether I do or do not have appendicitis -- if my pain persists. With the psychiatrist, I can tell him again and again that I am hearing voices but he will never nor cannot possibly tell me I do not have schizophrenia, nor any mental illness for that matter.

Anyone else who has responded to me on this topic I will get back to as soon as possible.

Valmont

Odysseus wrote: »

Valmont, have you read Discipline and punish, and the birth of the clinic or even Madness and Civilisation?

I have Madness & Civilisation on the book shelf, haven't read it just yet; would you recommend the other two?

LostPassword

Valmont wrote: »

I think you have misunderstood me. I'm not denying mental anguish or the importance of patient reports but your own example demonstrates the pseudo-scientific nature of psychiatry. A patient presenting with a complaint of a headache will be given some painkillers -- he won't be given a diagnoses unless the pains persist and he is referred to a neurologist. Now, this part is crucial:

Not true - neurology has no way whatsoever of confirming or denying the presence of pain - they can certainly test for various causes, but they cannot test for the pain and, in practice, in a great many cases they find no cause. Headaches, chronic back pain, etc, etc, are often treated without there ever being any positive test for a cause - just like psychiatry treats symptoms without there ever really being any detected cause.

Valmont wrote: »

Psychiatry is the only medical field where the practitioner cannot tell a patient they do not have a disease or illness. With the headaches or migraines, a neurologist can objectively confirm the presence or absence of a pathology. With the psychiatrists, all they have to go on is the patient's report, so if they patient keeps telling them they have symptom x, hey presto, they have a brain disease. No actual objective evidence needed -- so if psychiatry is a medical science, like neurology, why does it get special treatment?

You're totally wrong most GP visits lead to some sort of tentative diagnosis and treatment without there being any objective tests (and GPs are by far the majority of doctors). Your misunderstanding is highlighted by your use of the word "disease" - psychiatrists do not deal with diseases, they deal with symptoms and the terms that they apply to those symptoms are simply categorisations - it is not a pseudo-science because they use the scientific method in attempting to discover treatments that alleviate the symptoms - that's all that you can scientifically do when you're dealing with a set of circuits that's far beyond human analytic capacity.

Valmont

Lost Password wrote:

Your misunderstanding is highlighted by your use of the word "disease" - psychiatrists do not deal with diseases, they deal with symptoms and the terms that they apply to those symptoms are simply categorisations

Let's look at the definition of symptom:

Symptom: A physical or mental feature that is regarded as indicating a condition of disease, particularly such a feature that is apparent to the...

How on earth can one talk about symptoms and their easement without reference to an underlying disease?

In your example concerning pain you neglected to point out that in many cases, an objectively verifiable disease can often be found to be the cause. Not so with psychiatric symptoms though, no objectively verifiable disease is ever found; hence the subtle change in nomenclature: if mental illness is real i.e. somatic-pathological illness why isn't it called illness? The 'mental' prefix belies the metaphorical usage of the term.

Odysseus

Valmont wrote: »

I have Madness & Civilisation on the book shelf, haven't read it just yet; would you recommend the other two?

Yes I would, but I would also say wait until you have read Madness and Civilisation it is the easiest of his books to read. The other two are much harder, so after you read the first one you will have a sense of what you are getting into.

Valmont

LostPassword wrote: »

it is not a pseudo-science because they use the scientific method in attempting to discover treatments that alleviate the symptoms

Would you say applying the scientific method to the study of the existence of God represents a genuine scientific endeavour? What about using the 'scientific method' to look at ghosts and poltergeists? Applying the scientific method to made-up phenomenon does not constitute good science, and mental illness is no different in this case.

Odysseus

Valmont, I see a lot of Szasz in your points, I just copied a few brief points from a lecture on psych-diagnostics I do [apologies for being lazy but my hand injury is still effecting my typing]

In his book “The Myth of Mental Illness” [1970] Szasz argued that mental illness does not exist, in other words that it is a myth. Accordingly, he felt that psychotherapy could be divided up into two areas, brain disorders and problems in living.

Hence, he made a clear-cut distinction between what psychiatry calls functional disorders and those with no clear-cut biological basis. In relation to functional disorders Szasz states:

“…for those who regard mental illness as signs of brain disease, the concept of mental illness is unnecessary and misleading. If the mean that people so labelled suffer from diseases of the brain, it would seem better, for the sake of clarity to say that and not something else. [Szasz 1970]

Mental illness is a metaphorical illness, we can only describe a person as mental sick in the same way that a joke or an economy can be described as sick.

The viewpoint here is that individual cam be controlled in two ways, physically through being locked up in mental hospitals, jails, etc, or in a more symbolic way by being diagnosed as having a mental disorder.

Would this be anywhere near your position? Or am I misreading you?

Valmont

Odysseus wrote: »

Valmont, I see a lot of Szasz in your points
....
Would this be anywhere near your position? Or am I misreading you?

Yes, I have been influenced heavily by two of Thomas Szasz's classic books:

The Myth of Mental Illness
and
Pharmacracy: Medicine and Politics in America

But before I read any more Thomas Szasz I plan to read Madness and Civilization.