Archive for the ‘Thinking about psychiatry’ Category

Why are Psychiatrists Called Shrinks?

Thursday, March 20th, 2008

 

Here’s an answer from the internet:

‘The largest brain in the world was found in the head of an insane man, and the psychiatrist’s job is to remedy the psychological problems of people, thereby shrinking their head from border line nuts to a regular or average size’.

I’m not sure that this is right, and will be avoiding wikianswers for the foreseeable future. 

A wider internet search gives a consensus that psychiatrists are so-called because of a pejorative comparison between them and tribes whose custom it is to shrink the heads of their slain enemies.  I almost wrote ‘primitive tribes’ there, but I have no idea how to shrink a head, and it might be very difficult.  This ‘head-shrinking’ explanation sounds plausible. 

As luck would have it, I joined Camden Libraries* today, and membership has given me access to the complete online Oxford English Dictionary.  With this resource at hand I am able to tell you that the term was first used by American novelist Thomas Pynchon in his book ‘The Crying of Lot’, where he says:

‘It was Dr Hilarius, her shrink or psychotherapist’

This is merely the word’s first recorded use and doesn’t means that Pynchon invented the term.  He is famously reclusive, and so it’s unlikely I’ll be able to ask anyway.  This website suggests ‘magazine cartoons of the 1950′s and 1960′s were awash in cannibalistic natives, witch doctors and the like, so the imagery of "shrink" is not all that surprising’.  Like a lot of expressions it was probably in use before a novelist, like Pynchon, with an ear for vernacular, picked it up. 

I’m making less progress on the history of ‘trick cyclist’ and all I’ve managed to find out so far is that it’s a ‘humorous alteration of psychiatrist’ (OED again), which I knew already.  If anyone knows anything about this please let me know. 

*I love libraries.  It’s like going to a bookshop where you don’t have to pay anything. 

 

 

 

Are Psychiatrists Psychoanalysing you?

Wednesday, March 19th, 2008

 

Often, when I meet someone I don’t know and I tell them that I’m a psychiatrist, they say something like ‘Oh, so are you psychoanalysing me?’ I don’t exactly known what they mean, but I have a feeling it’s something like ‘are you looking into the deep recesses of my soul, and seeing things about myself that I don’t even know?’

Which would be a neat trick. 

I used to think that this was a relatively silly question, which shows a lack of understanding of both psychotherapy and psychiatrists.  For a start it assumes that all psychiatrists are psychotherapists, which is not the case; this misunderstanding is fairly universal within the media, so is understandable.  It also treats all psychotherapy as if it were one single approach (this being Freudian) and there are many many different psychotherapeutic methods. 

What people are actually saying is, if you are a psychiatrist you must be a psychoanalyst and if you are an analyst you must be a Freudian psychoanalyst.  It does, however, give an idea of the strange and mysterious powers that people might consider a psychiatrist to possess.  

Here’s a definition of psychoanalysis:

Psychoanalysis n. a school of psychology and a method of treating mental disorders based upon the teachings of Sigmund Freud (1856-1939).  Psychoanalysis employs the technique of free association in the course of intensive psychotherapy in order to being repressed fears and conflicts to the conscious mind where they can be dealt with. (Oxford Concise Medical Dictionary)

So, if we’re being picky, psychoanalysis involves a element of treatment and just dissecting someone’s personality apart when you meet them is not psychoanalysis, it’s being nosey.  

Lastly an important part of psychodynamic psychotherapy is in the therapeutic alliance formed between analyst and patient – this is unlikely to be formed during a ten minute conversation at a party.  Even the briefest of analyst-patient contacts involve sessions over multiple weeks. 

Recently, I have in a way begun to see what people mean.  We have a case discussion group at the hospital in which I work where one of our number presents the case of a patient, who for whatever reason sticks in their mind.  When I presented a history it became evident that there was a question that I hadn’t asked.  My position on this was that I had simply forgotten; the psychoanalytical view was that my forgetting had significance (perhaps I was subconsciously afraid to ask the patient?), as would my reaction to being challenged on my oversight.  The point is, that something relatively innocuous had provided information about me which others could now see but of which I previously had no knowledge. 

I now sometimes find myself being careful what I say lest it be interpreted in some way.  For example I hesitate to make a joke in case it betrays a discomfort with subject matter.  Is this what people mean?  As psychiatrists, and doctors in general, we’re observers of behaviour.  A neurologist is trained to spot a posture consistent with a neurological disease, an orthopaedic surgeon, a limp.  With psychiatrists it’s a little less concrete, but we’re all trying to spot signs that tell us that someone might need our help.  If that’s psychoanalysis, then yes, I suppose I am.

Psychiatrist vs. Psychologist

Monday, March 10th, 2008

Judging by how often I’m asked this question, there is a lot of confusion out there about the differences between psychiatrists and psychologists. For a lot of people the two professions are synonymous.

There is overlap between the two roles, and both professions deal with a similar group of patients; we both work for the well being of patients who have problems concerning their mental health or behaviour (or both). There are however a large number of differences.

Firstly, psychologists and psychiatrists have different training. A psychiatrist goes to medical school and, in the UK , will have spent at least a year working in physical medicine. A psychologist starts their training with a psychology degree, going on to higher degrees and has no medical background.

This leads us to the really big difference: psychiatrists can prescribe medications for patients (as ever there are exceptions to this – nurses can take a prescribing course, but their remit would mostly be restricted to commonplace short term medication, for example night sedation) and psychologists do not. Psychiatrists therefore spend a lot of their time initiating and monitoring pharmaceutical treatments and assessing patients’ mental state in the light of this.

In contrast to the psychiatrists’ focus on medication as a treatment for mental illness, a psychologist’s approach focuses extensively on psychotherapy and treating emotional and mental suffering in patients with behavioral interventions. This might involve problem solving techniques or identifying and tackling dysfunctional behavioural patterns perhaps via psychological therapy such as CBT. Psychologists are also qualified to conduct psychological testing, which is important in assessing a person’s mental state and determining the most effective course of treatment.

One final difference is that psychiatrists are also involved in involuntarily detaining patients on psychiatric wards when it is felt that a patient is at risk to themselves and/or others and cannot be treated in the community; this is not part of psychologist’s remit.

So, as a simple example, let’s say that a person is referred to a mental health team because of severe anxiety. Their psychiatrist would consider prescribing them anti-anxiety medication. A psychologist will be more focused on behavioural intervention. This might involve CBT or, with a phobia, graded exposure.

People also mix up the role of psychiatrists and psychologists with that of psychotherapists/psychoanalysts. Again there is overlap between this profession and psychiatry – but it’s a story for another day.

Added 14 June 2008

Here’s what ‘Psychology: A Very Short Introduction’ has to say on the subject.

‘There are some fields with which psychology is frequently confused – and indeed there are good reasons for the confusion. First, psychology is not psychiatry. Psychiatry is a branch of medicine which specialises in helping people to overcome mental disorders. It therefore concentrates on what happens when things go wrong: on mental illness and mental distress. Psychologists also apply their skills in the clinic, but they are not medical doctors and combine with their focus on psychological problems and distress a wide knowledge of normal psychological processes and development. They are not usually able to prescribe drugs; rather they specialise in helping people to understand control or modify their thoughts or behaviour in order to reduce their suffering and distress’

Added 13 August 2008

And in 1980 under Mao psychology was condemned as being

’90% useless’ and ’10% distorted and bourgeois phoney science’

Source: Bond M.H. 1995 Beyond the Chinese Face: Insights from Psychology

Via Affluenza by Oliver James page 128

Added 25 December 2008 (that’s right – nothing on television)

From Madness Explained Richard Bentall pp. 3 quoting Medicine balls Too pp. 78-9

‘Rob Buckman, doctor and humourist has characterised the difference between psychologists and psychiatrists in the following way: ‘According to psychologists, a psychologist is a scientist how has trained in various aspects of experiment psychology, neuropsychology, operant conditioning and interpersonal dynamics, whereas a psychiatrist is a doctor who couldn’t keep up the payments on his stethoscope. Psychiatrists on the other hand tend to view the schism in a more allegorical style. Thus according to a very senior psychiatrist, ‘neurotics are people who build castles in the air, psychotics are people who live in them, while psychiatrists are people who charge the rent, and psychologists are like men from the council who come round once in a blue moon, talk incomprehensible crap and do damn all”

Added 19 August 2009

Another viewpoint from Guide to Psychology

SSRIs in the doghouse

Tuesday, February 26th, 2008

It’s a bad time to be an SSRI antidepressant.

Strike one:

In January a paper in the NEJM found that the evidence base for the use of these drugs was incomplete, with a large publication bias towards positive results.  When negative results had been published, it was in such a way as to give these results a positive skew.  This publication bias in itself does not mean that a drug is ineffective, but hardly instills confidence.  There have been rumblings about this sort of thing going on for a long time….

Strike two:

A paper published today in the Public Library of Science Medicine Journal entitled Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration collected (via the freedom of information act) what it believes to be all the trial data available before their licence was granted (published and unpublished, positive and negative) on Fluoxetine, Paroxetine, Venlafaxine and Nefazodone, and found via meta-analysis their effects for mild and moderate depression to have no clinical improvement over placebo. 

This raises a number of concerns for psychiatrists and the population at large, several million of whom were taking these medications at the last count.

  • Already not especially convincing, where does this leave the monoamine theory of depression?
  • Have pharmaceutical companies deliberately mislead the doctors and patients as to the effectiveness of their product, thereby costing health providers billions of pounds and subjecting millions to ineffective medication and unnecessary side effects?  If so, shouldn’t we take them to court or something?
  • What should we tell our patients?  There are plenty of people out there on the above medications for mild/moderate symptoms of depression.  See end of piece for a quick summary of how depression is categorized.  Doctors who prescribe antidepressants in these circumstances will be aware that it’s not the best treatment, but wouldn’t wish to give somethings that really doesn’t work at all.  If these antidepressants were working because of a placebo effect then, with all this publicity, they won’t be working now.
  • What are we going to do instead?  NICE already recommends that counselling/therapy is the most appropriate intervention in mild/moderate depression.  However waiting lists are very long and many people crave a quick fix to their problems, which in any case are more ingrained than that which is amenable to a course of cognitive behavioural therapy.

Classification of depression

Depression as an illness is somethings that’s talked about a lot these days.  The first thing to say is that the difference between ‘depression’ as an illness and simply feeling ‘gloomy’ is not qualitiative but quantitative.  There is also no test for depression, but rather a line in the sand that when (methaphroically) overstepped people say that you are depressed.  The diagnosis of depression is made on clinical grounds rather than via a test.  This is not unusual in medicine, epilepsy for instance is diagnosed in the same way.

When we as psychiatrists, (but also as lay people, but in a less formalised way) say that someone is depressed, what me mean is that they are displaying a number of symptoms that suggest to us that their main problem is of low mood.  In order to make diagnoses more consistent and also to aid in professional communication psychiatrists use diagnositic guidelines for their diagnoses.  In America these guidelines are called the Diagnostic and Statistical Manual edition IV and in Europe we mostly use the International Classification of Diseases edition 10. 

(I’m almost there.)

Although mood and hence depression exists on a dimension, i.e. there is a continum from ‘not depressed’ to ‘very depressed indeed’ with no breaks in between, we choose to draw further lines in the sand and make categorical diagnoses – this is where the mild/moderate/severe depression diagnoses come from. 

So, when the above study talks of ‘mild depression’ it’s saying that a person meets the criteria for either the DSM-IV or ICD-10 criteria for depression.  The ICD-10 criteria are:

F32.0 Mild Depressive Episode: Diagnostic Guidelines
Depressed mood, loss of interest and enjoyment, and increased fatiguability are usually regarded as the most typical symptoms of depression, and at least two of these, plus at least two of the other symptoms described above should usually be present for a definite diagnosis. None of the symptoms should be present to an intense degree. Minimum duration of the whole episode is about 2 weeks.
An individual with a mild depressive episode is usually distressed by the symptoms and has some difficulty in continuing with ordinary work and social activities, but will probably not cease to function completely.

If you’re interested in classification of depression then try this site

Roundup

Bad Science on SSRIs and criticism of media response to PLOS paper

Guardian articles on PloS paper: Ann Robinson – If the drugs don’t work; Allegra Stratton – A bitter pill; Sarah Boseley Prozac, used by 40m people does not work, say scientists; Mark Lawson Something for Nothing

 

 

‘Nervous Breakdown’

Thursday, January 31st, 2008

My last previous post has got me thinking: what exactly is a ‘nervous breakdown’.  I muddled through five years of medical school without the curiousness to find this out, and still don’t know exactly.  The term certainly has no precise psychiatric or psychopathological use.  The Oxford English dictionary defines nervous breakdown as: ‘noun a period of mental illness resulting from severe depression or stress’ which could mean just about anything.  It also begs* us to consider the nature of ‘mental illness’ which is a difficult question in itself.  Always available to shine light were once darkness reigned, my favourite book, Campbell’s Psychiatric Dictionary allows us:

 

breakdown,nervous A popular, inexact term for the appearance of neurotic or psychotic symptoms of enough severity to impair significantly the person’s ability to cope with demands of his or her current life.  The term implies a relatively sudden onset of disability and/or readily discernible fall from a previously maintained level of performance of adaptation. 

 

Good enough for Robert Campbell, M.D. good enough for me.  Why it’s under ‘breakdown, nervous’ rather than ‘nervous breakdown’ is something I may ask him if ever we meet. As a bogus pseudo-medical term it has much company;  ‘critical but stable’ is a particular favourite of mine in this regard.  The use of nervous breakdown is euphemistic and perhaps its use widespread because of a desire to root something as frightening and unknowable as mental illness in something physical and accessible - ’nerves’. 

*You’ll note that I did not use the phrasing ‘begs the question’ here.  My usage of this phrase has been thrown into confusion following being introduced to the website www.begthequestion.info

The ‘it’s not me’ culture and the rise of psychoactive prescriptions or is there an epidemic of psychological disorders?

Sunday, December 23rd, 2007

In the 1950s and 1960s a pharmacological revolution produced an array of drugs for use in disorders such as schizophrenia, depression and anxiety which enabled psychiatry to move closer to the paradigm of physical medicine of administering specific cures for specific conditions. Consider the following statistics

In the UK the use of antidepressants increased by 234% in the 10 years up to 2002 (1).

In the USA 11% of women and 5% of men now take antidepressants. (2)

What can be causing this explosion in the demand for prescription antidepressants? It cannot be possible that in ten years the number of people suffering from depression in the UK has more than doubled.

Here are some of the possibilities:

In recent years we have been encouraged to view more and more problems that were previously considered to be normal and manageable parts of the human condition as mental diseases that require treatment.

The boundaries of well known disorders have been broadened. Psychiatric diagnoses are very changeable and what counts as a disorder is highly dependent upon prevalent social norms and beliefs. We are now inclined to medically characterise the ‘problems of living’.

Lesser known disorders such as panic disorder and social phobia have been publicised. These disorders can have a substantial overlap with normal experience. When this is the case the condition is then expandable, which allows the drug companies may claim that they abhor the inappropriate over-prescribing of their drugs safe in the knowledge that this will almost certainly occur anyway.

Drug treatment has started to colonise areas where it was previously thought to be unhelpful such as substance misuse and personality disorder.

Depression as a diagnosis has been promoted by drug companies, especially after the advent of Selective Serotonin Reuptake Inhibitors (It has been suggested that pharmaceutical companies turned their attention to antidepressants after the collapse of the market for benzodiazepines following the discovery of their addictive potential (3)

It is more acceptable to admit to being depressed

Antidepressants have become household names and books about them have become best sellers.

There are social advantages by being depressed. A ‘depressed’ person can be seen as less responsible for their behaviour and can lay claim to the sympathies of professionals, the resources of the welfare state and the language of victimhood.

Although we are living longer, our modern lives are becoming increasingly uncertain. The comforts of the welfare state are less, our working hours increased, job security decreased and pension schemes uncertain. We are actively encouraged by the media to be in a semi-permanent state of mild dissatisfaction in order to fuel consumer spending and are constantly fed a diet of soundbites fortelling imminent doom.

Why is this important?

Medications cost a lot of money. This money might be better spent elsewhere and could go towards other non drug based therapies

A society which has been convinced that it is ill is less likely to look for other solutions to tackling misery for example that their social conditions are caused by wanting Government policy and will be unable to mount an effective challenge.

Psychiatric illness is poorly understood and the ‘biological hypothesis’ of this sort of disease is unproven.

We disempower people by informing people that their only form of relief of their mental distress is via medication.
The idea that problems that were previously considered a manageable part of human existence are now only to be addressed with the help of professionals is likely to reduce personal coping stratgies (4) and reduce our self confidence’

Medications have side effects, some of these can be very serious and there have been allegations that pharmaceutical companies have sought to play down the harmful effects of their products. Many psychoactive medications have a deleterious effect on sexual function, something about which patients are seldom asked.

Ben Goldacre has made available an interesting podcast entitled ‘More than molecules – how pill pushers and the media medicalise social problems’ – in which he argues that the media are locked in a ‘Miracle cure/sinister hidden scare’ model and that pharmaceutical companies seek to sell us preparations which they invite us to believe can cure complex social problems.

1 National Institute for Clinical Excellence (2004) The Treatment of Depression in Primary and Secondary Care. London: NICE
2 Stagnitti, M. (2005) Antidepressant Use in the US Civilian Non-Insitutionalised Population, 2002. Statistical Brief #77. : Rockville, MD: Medical Expenditure Panel, Agency for Healthcare Research and Quality.text
3 Healy, D. (1999) The three faces of antidepressants. Journal of Nervous and Mental Disease, 187, 174-180.
4 Moncrief, J. (2003) Is Psychiatry for Sale? Maudsley Discussion Paper