Friday, February 14, 2014

Heat Map of Psychiatric Criticism

On my drive home today I got the idea of a heat map of psychiatric criticism based on the principles outlined in my previous post.  I have started one as shown in the diagram below.  The heat zones on the map are general areas corresponding to the parameters outlined in the previous post on rhetoric.  In other words red and redder would correspond with more irrational and rhetorical criticism.  Green and greener would be more rational criticism and less rhetorical.  See the previous post for supporting arguments.

I have started out with a few examples in each zone.  I would like to be exhaustive here so send me your favorite one liners about the profession or your most hated psychiatrist and I will try to place it on the heat map.  Just a heads up, no personal attacks or identifiers will be tolerated.  It may be hard to believe but this is nothing personal.  I hope to provide a simple graphical solution to the question of what is and what is not appropriate psychiatric criticism.

I also thought about a couple of reasons why this is important.  Several years ago a friend of mine called me up and asked me a question about the American Board of Psychiatry and Neurology.   He wanted to know what year it was incorporated.  I told him I thought it was on my certificate and I would call him later.  When I got home I looked at the certificate and sure enough it read: "Incorporated 1934".   I called him with the information and asked him why that was important.  He is a social worker and told me that he was at a major DSM training course attended by social workers and the speaker (who was not a psychiatrist) suggested that psychiatry was such an illegitimate field that they were not even one of the original specialties and decided to form the ABPN later in order to seem more legitimate.  And this was a guy who was teaching a DSM course!  In another similar session, the presenter (also not a psychiatrist) compared the validity of psychiatric diagnoses referring to the Robins and Guze criteria to the validity of drapetomania.  For anyone not familiar with this definition, it refers to the idea by a 19th century quack that a slave running away is somehow a mental illness.  It really has no connection at all to the idea that there are valid mental illnesses that can be diagnosed and treated.  And yet here we have a professional making this comparison.  The term was also used in a periodical that is valued for its intellectual appeal, but the interview is embarrassing to read especially the tortured attempt to connect it to DSM-5.  My speculation is that the people who use this term have an additional agenda.  It is clear that there are are many uses of the loose application of this rhetoric and gaining political advantage is often an overlooked one.

As I look at my initial attempt, I am realizing that I need to figure out a way to group all of the statements at the top firmly in the red zone so that none of them touch the transition area to the green zone.

George Dawson, MD, DFAPA

Supplementary 1:

Here is a working list to consider (click to enlarge all graphics on this page).  This is the second version and as of today (2/16/2014) no outside suggestions.  The image below is formatted to print or store as a single 8.5 x 11 inch page:


  1. I haven't commented or read your blog since your "anti-psychiatry are bullshitters" entry that I found offensive. I'm sorry if I offended you first. I just looked and I saw you got a lot of attention a few posts back. I thought about this chart, and I have some input for it.

    Here are some lines that you could add to this list:
    - Psychiatric symptoms are not disease specific, and are not good enough to differentiate one illness from another

    - Objective risks can not be realistically weighed to Subjective benefits in practice
    (E.g, 'improvement' of psychosis and psycho-surgery)

    - Mental illness is too broad a label and encompasses too many types of causes to be appropriate for also labeling the insane (biologically sick).

    - Psychiatry must replace "Mental Illness" with "brain dysfunction" to make scientific progress and allow engineers to develop better diagnosis and treatment

    - Medical evaluations by psychiatrists are uniformly poor

    - Psychiatry as a field did not adequately advocate for the civil rights of it's own patients.

    - Human rights violations have little or no system to be addressed in psychiatry, and still remain a significant global problem, most notably in poorer countries.
    ((Psychiatry in the past, by 1960, had imprisoned 800 thousand people in the US (equal to half of all criminals imprisoned in the US today), persecuted the not-sick (the gays), and killed tens of thousands with 'ice pick' brain surgery, shock therapies, and other drugs. Many more were rendered irreversibly damaged. There was nowhere to complain to.))

    - Neurology made more progress then psychiatry and would be a more ideal approach.

    I don't really don't feel the need to defend anti-psychiatry, whoever they are, however, I think public discontent is rational and well founded. Psychiatry has a lot of problems and no clear way forward.

    I'm only sorry that anti-psychiatry is not organized and thus mostly wastes their efforts and gives everyone a headache (including me). Especially the sick seeking help who don't know what to make of it all. I wish they could agree what it was they wanted so they had a uniform message.

  2. You did not offend me. I am not offended but simply do not tolerate threats, ad hominem attacks, and sophistry. Your anecdotal experience is probably no more generalizable than mine. Keep in mind that of all of the physicians I have seen for physical problems the odds have been that only 1 out of 5 doctors (none of them psychiatrists) can make an accurate diagnosis. I am currently in the midst of a month long episode of illness where I am being treated presumptively for an exacerbation of asthma and nobody (I have seen 5 doctors - none of them psychiatrists) seems to know why it is not getting better or why after having asthma for over 30 years this is by far the worst episode. No positive medical tests and all syndromal diagnosis. Maybe we need to get engineering in primary care?

    On the other hand, my work with top groups of psychiatrists is completely the opposite to what you describe and for over 20 years I taught a course to prevent the misdiagnosis of a physical problem as a psychiatric one and making physical diagnoses that were otherwise missed was commonplace.

    When you talk about human rights violations, you apparently have no idea about how country jails across America have become psychiatric hospitals. You can rejoice, there really is not much functional psychiatric care in hospitals in America any more. The three largest "psychiatric hospitals" are county jails. So you won't have to worry about civil rights violations any more. Many people with severe problems will just start off in jail. They will all get the standard warning about their rights.

    Just a final reminder - psychiatry is a medical speciality at least the way I am used to seeing it practiced. That is where the focus needs to be especially with all of the ill will that seems to coincide with big business interests. It would not shock me at all to see the field replaced in a decade or two by a large number of "prescribers" whose only job is to put people on medication as soon as possible. They will be underwritten by major health care corporations and the governments.

    Good luck organizing against them.

  3. You might like making an infographic vs a heat map. Just a thought.

    For your medical issues, I feel your pain. Sleep apnea, silent reflux and sub-clinical hypothyroidism makes for a fun time. Not really. Standard treatments don't help my sleep or fatigue levels so de facto PCP answer is always antidepressants (which I won't take except Silenor prn). Nothing is invested in finding the cause of any and all above issues. Yet I worked in hospital pharmacy for over ten years so I know there is a whole lot to be done about it.

    Like you, I am also concerned about slash and burn hopes of the "anti-psychiatry" crowd. A couple of days ago I wrote a comment about this on Shrink Rap blog thread under "Are Psychiatrists Evil?" I didn't mention jails but it was one of the things I had in mind when thinking about the law of unintended consequences.

    1. The infographic looks interesting. Agree completely about the slash and burn. Most of the critics don't even realize what they are attempting to slash and burn. The commentaries about 18th and 19th century psychiatry and the implications for psychiatry today in the absence of ANY comments about managed care are the most obvious examples. Most of the scorched earth critics don't realize they are rearranging the deck chairs on the Titanic.

      Good luck with that.

  4. I'm sorry about your health, I hope that improves. One of my best friends suffered from asthma as a kid; he would turn blue, it was quite scary. Lucky for him asthma inhalers seemed to work somewhat. I hope you get well soon.

    Engineers can build anything required as long as they have the practical knowledge to work with. Unfortunately one has to get companies to spend money to research into the cause of disease in order to get that knowledge.. I guess that doesn't fit the pharmaceutical industry's business model anymore. Most treatments are based on "it works but we don't know why".

    I never met a "top psychiatrist" personally, most of the people I met were average and only 1 of the 5 offered psychotherapy. I think that one was my favorite out of the bunch and actually did help.

    Yeah, I'm aware that today our prison system contains 25% of the worlds prisoners, yet our population accounts for just 5% of the world. We also have a drone program that is probably illegal, and then theres Guantanamo Bay where people are illegally detained and tortured for a war on a human emotion called 'terror'. Not sure how that makes sense?

    I think most of psychiatry has already been replaced by the 'prescribers' you described. I read somewhere a few years back only about 11% of psychiatrists still offer psychotherapy in the US. So 89% could just be bus stops? There were 33 million prescriptions for anti-psychotics in 2010, the vast majority written by psychiatrists. 5.5 million of which were to children, and 350 thousand to toddlers. The report came from the FDA :(


    Can I tell you a personal story? My first experience with psychiatry was involuntary, a decade ago. I had a severe B-12 deficiency and experienced severe depression (also blackouts/seizures) . I was misdiagnosed with "situational depression", told I had a "chemical imbalance", prescribed an off-label antidepressant (lexapro), and then forced to receive ECT without my, or my parents, consent within 2 weeks of admission. On top off all that, I was denied treatment for my B-12 deficiency because the psychiatrist in charge told my parents that she did not believe B-12 deficiencies could "exist", and threw out my blood-work results on the grounds "the test must be wrong". I don't remember most of the 30 days I was there, but I called one of my friends 'terrified' apparently.

    I was hospitalized because a GP tricked me into signing a form. He had explained that B-12 deficiencies were "the most common cause" of unexplained depression. None of the psychiatrists I saw had heard that when I asked.

    Lexapro did not work and made the depression worse, but I was unable to discontinue it. I wound up carving myself up for a year or so. I acted pretty crazy from the drug, made a lot of very poor decisions. I was never able to go back to school, at least in part from 7 years of drug side effects. I wanted to be a systems engineer, yet today I've been disabled for the last 3 years from a protracted withdrawal syndrome (that's a suicide trip itself) and haven't been able to work. On the plus side, I haven't taken a psych drug in my first 3 years in a decade and my head is clearing up nicely.

    I don't really understand what Mental Illness is supposed to be. Every psychiatrist I asked had a different definition or belief. It made me very upset, but other people got hurt worse then I did; I never wanted to hate psychiatry or make anyone's life miserable. I have met so many people who got hurt, it seems as if they are everywhere. I think I'm going to take a break from all this for awhile. I don't know if I really have anything more to contribute. I wish you well and everything, and good luck with all this. Thanks for considering to listen, I wish I had more varied input.

    I don't know how many of the lines I suggested could fit into the green zone, but I hope that some could. I hope maybe it makes sense why I chose those.

    1. The care you describe is certainly not the standard that I am used to. For example, screening for B-12 deficiency and a number of other problems is standard. Treating B-12 deficiency is standard and so is waiting to see if it has any effect on the mood before trying and antidepressant if that is the person's preference. It has been reviewed in standard psychiatric texts like Lishman's Organic Psychiatry since the first edition. It is seen as an endocrine/metabolic cause of depression, cognitive and neurological problems. That is not a belief - it is a fact and it is recognized by the DSM - you can't have a functional syndrome if an organic etiology has not been ruled out.

      I don't know how you can get ECT without consent unless there is a court order form a judge. In the state where I practice it would take a civil commitment hearing followed by a special hearing regarding ECT. The entire process might take 3 - 4 weeks. Nobody can trick you in to signing a form because you can submit a request to leave at any time and you can only be held involuntarily if certain criteria are met. Legal penalties and civil liability would occur if the legal procedures were not followed.

    2. I don't know how the person who treated me has kept her license; she is still head of the ward at that hospital. I don't know what the laws were ten years ago in my state, but I'm aware court hearings are required now and that changed. I was released after my insurance ran out and my parents had refused to pay. If there was any way to apply for release I guess nobody told me. I don't know if I actually did receive ECT or not, my parents were under the assumption that it was likely to happen, I was not able to get my medical records at the time and still have no idea what exactly they did. It's possible Lexapro by itself had some very similar side effects.

      Unfortunately for me, 'certain criteria' was subjective. Court hearings are helpful, but aren't really a mechanism to allow someone who is sick to decline treatment. I'm aware some states like California actually allow patients to decline some treatments, but not here.

      I have a best friend who's brother was institutionalized for years, and his family decided to hire a lawyer to help get him out. After a year or so of proceedings, a judge decided the institution could not produce satisfactory evidence for why he was on medication or what basis he was being detained on, and released him.

      He was very bitter about it for years; he pretty much grew up to a teenager in an asylum that apparently seemed to have had no idea what his diagnosis was. His mother told me his file produced in court was a foot thick.

      I never figured out why I was treated the way that I was all those years ago, but I tried to find out, and learned a lot more about psychiatry. I don't think that legislation could ever fix this problem, I think that psychiatry and anti-psychiatry need to find a common item where a compromise can be found. Actually, feel free to rephrase my line in a more neutral or different way if they can work, I just realized some seem a bit more like biased opinions. All of those things I have heard out there.

  5. I don't know what state your were in, but I can tell you that over the course of my 30 year career there have always been court hearings and plenty of them. It is part of residency training. In these proceedings in the states I am familiar with (Minnesota and Wisconsin) the paper trail is clear and the person who is in the commitment, guardianship, protective services, or protective placement hearing is informed at every step and typically ends up with a pile of paperwork including the final decision of the court.

    The problem with laws is that despite their appearance the interpretation is totally subjective. For example in Minnesota these hearings are on a county by county basis and I have heard that since we have 87 counties there are 87 different interpretations of the law. Those interpretations also have to do with how many resources a county has to treat persons with mental illness and what type of accounting occurs if anyone ends up being committed and sent to a state mental hospital.

    Anyone in a situation where they are undergoing a hearing for some type of involuntary treatment should be seen is a specialized setting where the psychiatrists and staff are used to dealing with that level of a problem. Insurance should not be a consideration in fact every insurance I know will stop payment once the court process begins. Discharging a person with a severe problem because the insurance stops should not be an option and it usually is not for any other type of medical or surgical condition.

    As far as I can tell there is no compromise possible between psychiatry and the detractors. As obvious from some of the posts on the "Psychiatry Gone Astray" thread - they really have no interest in psychiatry, have entrenched biases, and in many cases will settle for nothing less than the wholesale destruction of the field. I would go as far to say they are so blinded by this bias they don't realize how effective managed care and the US government has been in destroying the field so far.

    I could come up with a post on what to do if anyone finds himself in the situation you describe. At the minimum there need to be meeting with the person involved and their family and there needs to be a clear plan for transition from the hospital. With the current level of fragmentation in the system, that pathway is often not very clear.

    1. I forgot to add a comment on the licensing issue. Every state I am aware of has a very low threshold for filing a complaint with the licensing board. Basically all complaints are accepted and the physician and facility involved has to respond in detail to the medical board. The medical board never determines whether they think the complaint is accurate or not - they simply decide on whether action needs to be taken against the licensee. In Minnesota all complaints are kept on file whether the board takes action against the licensee or not.

      Speaking as a physician - that is a very low threshold for accountability.