What Does ERISA Say About AI Guardrails?

 

 

A colleague sent me a news article this morning about a couple suing a major AI firm for advice given by their chatbot to their son resulting in a fatal overdose.  As a psychiatrist most of what I read about problematic AI comes in the form of AI hallucinating false medical references (1), AI induced psychosis in people who either use it excessively or who are predisposed, or AI facilitating its own use by excessive praise or obsequiousness.  In the latter case it can result is emotional attachment to the AI that of course is unwarranted.  I have also flagged a couple of cases that illustrate the problems when AI is applied to moral and political decision making.

I decided to do a little more research on the subject.  I was surprised to find a Wikipedia page titled Deaths Linked To Chatbots. Thirty-three deaths are listed not including the case I was investigating. The suggested pathways to violence generally include overuse, emotional attachment, and bad advice biased toward reinforcing irrational decisions.  The evidence contained on this page highlights a couple of concepts that might not be apparent to most people including the architects of AI.  The first is the importance of emotion in human decision making. This was articulated by Bechara in the past who demonstrated that if there is a disruption between emotional and cognitive systems in the human brain – even basic decisions become impossible.  Other disruptions in the same systems can lead to an array of emotional dysregulation and the associated irrational and often socially inappropriate decisions.  Second, emotional biases clearly affect decision making in the case of intact brains.  There is perhaps no better example than the current American political system installing a less competent government that is clearly not in support of the wants and needs of most Americans.

Secondly, humans can form intense attachments to inanimate objects that are unable to reciprocate.  The classic example is developmentally normal transitional objects (stuffed animals, toys, blankets).  Winnicott theorized that in infancy – this object is recognized as not part of the self or external reality.  It is a fantasized relationship that represents a future “illusion”(2).  According to Winnicott’s theory the transitional object loses meaning during normal development and becomes irrelevant.  Persistence into later stages may indicate a normative transition like object attachment during grieving, to a way to compensate for the lack of interpersonal attachments, to personality or psychopathology. 

Chatbots can be significant attachment figures and this is currently an area of study (4-6).  The area of human – digital object transference is also being explored (6) as well as the projection of human needs onto a digital object (8), and more complex models of human-machine connectedness (9).  This literature is referenced primarily to indicate that there is a lot that is not known about the array of human responses to interactions with these machines and what the possibilities are.

Apart from my previous concerns that machines lack consciousness and have demonstrated a lack of adequate moral decision-making there is always the question of programming and algorithms. Both of the features are the bane of most Internet users who find that their most mundane interests are often amplified to result in a barrage of advertisements and sales offers.  And then there is the army of misinformation bots spreading foreign and national political propaganda 24 hours a day.  None of that requires AI but is there any doubt that AI will make it worse and harder to detect?

It is no secret that the current AI explosion is a multitrillion dollar enterprise being run by a handful of men who have shown no interest in the environment, social equity, or human rights. They immediately aligned themselves with an autocratic government at the highest levels and so far, have had no regulation of their AI.  As a result, that AI is spewing out massive amounts of information that the average citizen is taking as legitimate if not some type of advanced advice. The complications of that advice include the deaths, environmental damage from the required power generation, and societal damage from unemployment.  There is additional damage based on inequity from wealth concentration.  The barrage of pro-AI hype in the media greatly exceeds any realistic discussion of the downsides.  The only clear benefit that most people see is their ability to sit at home and entertain themselves with a chatbot or see if an AI can do their homework or other projects.  The purported efficiency seems offset by a tremendous amount of time wasted.

At the minimum – in the case that started this post there is a stark contrast between human decision makers and AI.  In 40 years of practice – I never recommended kratom by itself or with alprazolam (Xanax) or Benadryl (diphenhydramine).  In fact, I spent a considerable amount of time getting people off of alprazolam and later kratom. But I am not unique in this – I don’t know of any physician who would make these recommendations.  But those recommendations form the basis for the AI lawsuit. 

That highlights the danger of the current hype that AI will replace physicians or the predictable studies that comparing AI to physicians shows that AI can be safely consulted.  There are even stories that AI is prescribing drugs in some settings without physician input.  The question of agency is never addressed and that seems like the basis for this lawsuit.  Corporations always seem to do good job of avoiding responsibility in healthcare.  The classic example is the Employee Retirement Income Security Act of 1974 (ERISA).  The pre-emption clause of ERISA means that in employer-sponsored health plan covered employees cannot bring state malpractice or negligence claims against their managed care organization (MCO) for injuries from denial of plan benefits, utilization review decisions, failure to use qualified physicians, or improper plan administration.   The reviewing physicians working for MCOs are also generally protected and the associated arguments are that utilization review is not the practice of medicine and/or the reviewers have no accountability/duty to the patient. Several studies have documented the patient harms related to this accountability gap and despite several attempts at amelioration it remains largely intact and a considerable source of financial success for managed care organizations.

The critical question is whether this kind of accountability gap will exist with AI.  It is easy to envision a scenario where AI is implemented to review charts and prescribe low risk medications like many online services do now.  Will AI eventually take the place of physician reviewers employed by MCOs? Will consumers and patients be led to believe that AI is making decisions that affect their medical care based on the best available information or in the interest of the corporation. Current statistics suggest that there are tens of millions of these decisions made every year.  AI can greatly increase that as well as the harassment factor if decisions are being appealed.

With all of the political talk about guardrails for AI – it is important to recognize that these guardrails need to exist at several levels.  Right now, it is not much of a stretch to say that AI is out there practicing medicine without a license. In the majority of cases like the initial example, the user does not know if the search result if strictly from medical literature or something else.  The user does not know if the AI is exercising the judgment of an average physician or in malpractice parlance using the community standard of care.  The user does not know if their psychology in terms of defense mechanisms or attachment style to inanimate objects or AI is being exploited.  The user does not know if the AI is just telling them what they want to hear.  And the user does not know if the AI is providing information in their best interest or the interest of corporations or the government.

I read a study doing research for this post and subjects were asked to rate the professionalism of the AI.  In my opinion the single-most significant determinant of professionalism for physicians is accountability and duty to their patients.  It fuels not only the immediate encounter but the concept of life long learning and service to patients. It is usually evident over time but only indirectly in the form of positive results and a positive relationship over time.  AI in its current form does not have it and I am not convinced that a society or culture that came up with ERISA can construct physician-like guardrails around medical AI.   

 

George Dawson, MD, DFAPA

 

1:  Topaz M, Roguin N, Gupta P, Zhang Z, Peltonen LM. Fabricated citations: an audit across 2·5 million biomedical papers. Lancet. 2026 May 9;407(10541):1779-1781. doi: 10.1016/S0140-6736(26)00603-3. PMID: 42107362.

2:  Kernberg OF.  Object relations theories and techniques.  In:  Textbook of Psychoanalysis, 2^nd ed.  Person ES, Cooper AM, Gabbard GO, eds.   Washington DC: American Psychiatric Association Publishing, 2025: 57-75. 

3:  Bachar E, Canetti L, Galilee-Weisstub E, Kaplan-DeNour A, Shalev AY. Childhood vs. adolescence transitional object attachment, and its relation to mental health and parental bonding. Child Psychiatry Hum Dev. 1998 Spring;28(3):149-67. doi: 10.1023/a:1022881726177. PMID: 9540239.   

4:  Cheng N, Yu R. Measuring and understanding emotional attachment in human-AI relationships. Ergonomics. 2026 Feb 2:1-20. doi: 10.1080/00140139.2026.2622539. Epub ahead of print. PMID: 41622967. 

5:  Liu T, Lo TY, Wen KH, Sun Y, Wei ZQ. Pathways of long-term AI virtual companion app use on users' attachment emotions: a case study of Chinese users. Front Psychol. 2026 Jan 12;16:1687686. doi: 10.3389/fpsyg.2025.1687686. PMID: 41602682; PMCID: PMC12833267.

6:  Koles B, Nagy P. Digital object attachment. Curr Opin Psychol. 2021 Jun;39:60-65. doi: 10.1016/j.copsyc.2020.07.017. Epub 2020 Jul 22. PMID: 32823244.

7:  Holohan M, Fiske A. "Like I'm Talking to a Real Person": Exploring the Meaning of Transference for the Use and Design of AI-Based Applications in Psychotherapy. Front Psychol. 2021 Sep 27;12:720476. doi: 10.3389/fpsyg.2021.720476. PMID: 34646209; PMCID: PMC8502869.

8:  Saracini C, Cornejo-Plaza MI, Cippitani R. Techno-emotional projection in human-GenAI relationships: a psychological and ethical conceptual perspective. Front Psychol. 2025 Sep 29;16:1662206. doi: 10.3389/fpsyg.2025.1662206. PMID: 41089650; PMCID: PMC12515930.

9:  Boyd RL, Markowitz DM. Artificial Intelligence and the Psychology of Human Connection. Perspect Psychol Sci. 2026 Mar;21(2):192-220. doi: 10.1177/17456916251404394. Epub 2026 Jan 29. PMID: 41608879; PMCID: PMC12960742.

Why Psychodynamic Psychotherapy?

 

I am not averse to top ten lists and came up with 8-points initially but easily found another two.  I have had a few posts over the past year based on my experience in a psychotherapy seminar that I coteach with several experienced instructors.  We meet 2 hours a week – every week over the course of the year.  The first hour is a didactic based on the Cabaniss text Psychodynamic Psychotherapy: A clinical manual. (2).   Over the course of the year, we cover every bullet point and entering into this later than my colleagues – I have been impressed with the level of discussion from both the faculty and residents.  The second hour each week is dedicated to the discussion of specific cases.  Different perspectives are encouraged.  I have made note of when I got an idea for a post here from participation in that seminar.  This teaching format was carefully designed over the course of many years by the instructors who were there long before I joined.  They also describe it as a format where clear improvements can be observed in the residents practicing the techniques.  

Several issues come up when psychotherapy training is discussed for psychiatrists. Over the years it has been a hot political issue.  As previously noted – many people like to characterize the history of psychiatry in an oversimplified manner.  The original asylum psychiatrists had little more than moral treatment of Pinel and Tuke.  That was followed by a period of brain based descriptive asylum psychiatry focused on neuropathology and phenomenology.  That was followed by a period of psychoanalysis and psychodynamic psychiatry.  And finally biological psychiatry starting in about the mid-20^th century with advancements in somatic treatments.

That is the timeline that is typically used to describe American psychiatry – but things are always more complicated.  I trained in the 1980s when departments were often split between the psychotherapy staff and biological psychiatry staff – but the split was really an illusion.  The residents were trained in both. I trained with some of the top biological psychiatrists in the country and they also did psychodynamic formulations and psychotherapy.  During my 3 years of residency, I was supervised for an hour for every hour of psychotherapy I provided every week in addition to the training seminars in psychotherapy.   

At the national level experts in psychotherapy have always worked and published in parallel to the biological psychiatrists and neuroscience-based psychiatrists.  The reality is that you cannot practice psychiatry well without being able to integrate the medical, biological, and the psychotherapy dimensions of the field. 

A general psychotherapeutic approach to the patient is required in psychiatry for several reasons. All medical students learn diagnostic interviewing beginning in the first year of medical school. The basic principles are empathy and open-ended questions.  There is not much content about immediate problems in the interview, how to discuss difficult topics, how (or why) to expand on the phenomenology, and what to do about your personal reactions to the patient.  In a previous post I have discussed this as a reason why supportive psychotherapy is the clinical language of psychiatry.

The evaluation in psychiatry is very often an intervention point. It is not possible to interview the patient in a crisis and have them return at a later date to address the crisis.  Talking and psychotherapeutic interventions are the mainstay of crisis intervention. The psychiatrist needs to assist the patient in resolving the crisis.  These crises can happen at any point in time – even in patients who have been doing well for years.  A psychiatrist always needs to be prepared to do crisis intervention at any point in time and that involves good psychotherapeutic skills. 

Psychotherapy is the treatment of choice for many disorders.  It has been used for decades to treat severe personality disorders and the consensus lately is that it is the preferred treatment over medication in some of those scenarios.  The landscape can be confusing because branded and manualized therapies are often used in clinical trials and even though they can get equivalent results.  It is probably safe to say that psychodynamic psychotherapists used to shifting from supportive to interpretative modes see much of what they do in these psychotherapy manuals and trials.

The therapeutic alliance is most explicit discussed in psychodynamic psychotherapy. It has been written about for decades and is important in all aspects of individualized psychiatric care.  In training it is also discussed as an important anchor point for clarifying the treatment process during periods of conflict or impasse.

Treatment setting is an important aspect of psychiatric care.  In acute care settings, the patient population is selected based on problem severity, lack of response to other therapies, need for additional modalities, and team-based care.  Transference and countertransference is complicated by the fact that it is now occurring at the team and institutional level.  Any psychiatrist working in that setting needs to be able to figure that out and intervene before there are any major problems and assist the team in managing reactions to specific patients and families.

Most of the suggested guidelines for psychotherapy training in residency are competency based rather than based on time.  The reality of training is that there is a shortage of staffing for any centrally recommended training program.  Programs are left to their own devices to provide training in this area. An untapped resource in many areas are retired psychiatrists and therapists who might be willing to volunteer to continue teaching.  That has been my role in this seminar and I find it highly rewarding. 

Training in psychodynamics and all of its theorists also provides and important historical context for the profession.  How were the original concepts modified over the years? Are some of these approaches and concepts (attachment theory, interpersonal psychotherapy, existential psychotherapy, infant psychotherapy, self-psychology, etc) still useful today? 

The most significant aspect of psychodynamic psychotherapy is the unique focus on consciousness. Unless you read about consciousness research explicitly this is the only place where that occurs.  I mentioned last week that when I attended medical school the emphasis was on objectivity and classifying people according to their disease and how well it could be characterized and whether those findings could be replicated. You do not have to be particularly bright to see the shortcoming of this approach.  No two people with asthma, brain tumors, or anemia are alike even after saying they have the same disease.  Their physical state, the way they think about it, their response to treatment, and the way they interact with you as their doctor is unique. In figuring out how to help them with whatever their psychiatric problem is – a diagnosis is only part of the story.  It requires thinking about who they are and why they might be reacting to things the way they do – a formulation.

Finally, and probably most importantly – psychodynamic training prepares the psychiatrist for what is ahead.  The first 5-10 years in practice is a potential minefield.  In today’s practice environment – psychiatrists are often overworked, seeing many people with severe medical and psychiatric problems who also have potentially severe interpersonal problems. Those problems are generally focused on aggression, sexuality, power dynamics like money and autonomy.  There is a general negativity about psychiatry in the press and on social media – largely from people promoting their own interests.  All of that can result in highly stressful situations in practice – especially if there are no colleagues around for consultation.  A psychiatrist can develop anxiety about some of these problems in practice and what can be done about them.  Although the issue has not been studied in the literature – my speculation is that psychiatrists trained in psychodynamics – especially if these topics have been explicitly discussed in training are more prepared to solve them in an effective way than psychiatrists without that exposure.  A typical way this issue is approached is to suggest rules that should not be violated.  Understanding what is happening at an emotional level is probably a better approach.

Reducing the mystery of psychotherapy and having a good idea of how it works is a clear goal. There have been times in my studies where the interventions seemed vague and which interventions were useful was not clear.  I can recall a few highlights over the course of my career that were very enlightening.  The first was a seminar with Otto Kernberg, MD about 30 years ago.  He provided the clearest definitions of the three basic intervention in psychoanalysis and psychodynamics that I have heard.  He described them as, clarification, confrontation and interpretation.  Clarification in this case is communicating the therapists empathic understanding of the patients experiences over time at the conscious and preconscious level.  Confrontation is not the usual adversarial sense, but is used to point out inconsistences or patterns in the patient’s narrative that may have escaped their attention.  In the seminar I attended, Kernberg pointed out that many people may be holding these inconsistencies outside of their awareness and the confrontation serves bring things together in a consistent narrative.  Finally, the interpretation connects patient's conscious experience and unconscious defenses, wishes, or conflicts.  Learning how to do that involves both reading about the theory and basic cases as well as seminar discussions with input from faculty and residents.   

Many consider the interpretation to be the mysterious part of psychodynamics and the secret handshake of this kind of psychotherapy.  It becomes more intuitive with a specific frame for psychodynamic therapy.  The two best examples I can think of are Interpersonal Psychotherapy and the Psychodynamic Life Narrative.  In the first case, Klerman and Weissman used psychodynamic principles to design a manualized therapy for depression.  It was subsequently applied to substance use disorders. Viederman designed the life narrative approach for crisis intervention in college students.  Both therapies are formulation based and designed to be used on a short-term basis.

The flexibility to go from an uncovering or transference based psychodynamic psychotherapy (TFP) to a supportive one is a critical skill.  There are people who will do better with supportive therapy and others who do well with TFP but in a crisis will do better with a supportive approach.  There is a broad range of flexibility in psychodynamic psychotherapy with supportive interventions that are identical to therapies taught separately as cognitive behavioral therapy, and behavioral therapy.  It also provides a framework for existential psychotherapy.     

Mechanisms of change in psychotherapy are written about broadly across therapies and specifically for psychodynamic psychotherapy.  It is safe to say that psychodynamic psychotherapy is more focused on the relationship with the therapist and the central role of emotions and insight. 

That is my brief commentary on the importance of psychodynamics and psychodynamic therapies in psychiatry.  There are many clinical trials for specific conditions that show psychodynamic therapy is effective. Some of those trials are 40 years old at this point.  We have many branded therapies advertised for specific conditions with features that overlap both supportive and psychodynamic psychotherapy adding further support to the claim it is a good approach to teaching psychiatrists.  When I look at the training recommendations for psychiatrists –  if you are running a training program and look at the three choices – psychodynamic psychotherapy should be preferred.  It covers two of the three types of therapy, has a rich history of involvement by psychiatrists at the clinical and theoretical level, and probably provides trainees with a better model for analyzing problems that occur in their future practices.

 

George Dawson, MD, DFAPA  

 

 

References:

 

1:  Kernberg OF.  Severe Personality Disorder: Psychotherapeutic Strategies.  Yale University Press; New Haven; 1984: 381 pp.  

2:  Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES.  Interpersonal Psychotherapy of Depression.  Basic Books, Inc; New York; 1984: 255 pp.

3: Viederman M. The Psychodynamic Life Narrative. Psychiatry. 1983 Aug;46(3):236-246. PubMed PMID: 27719516.

4:  Holly A Swartz.  Interpersonal Psychotherapy (IPT) for depressed adults: Indications, theoretical foundation, general concepts, and efficacy. In: UpToDate, Roy-Byrne P (Ed), UpToDate, Waltham, MA, 2018.  Accessed February 17, 2018.

5:  Wampold BE. How important are the common factors in psychotherapy? An update. World Psychiatry. 2015 Oct;14(3):270-7. doi: 10.1002/wps.20238. PMID: 26407772; PMCID: PMC4592639.

6:  Høglend P, Hagtvet K. Change mechanisms in psychotherapy: Both improved insight and improved affective awareness are necessary. J Consult Clin Psychol. 2019 Apr;87(4):332-344. doi: 10.1037/ccp0000381. Epub 2019 Jan 10. PMID: 30628797.

7:  Churchill R, Moore THM, Davies P, Caldwell D, Jones H, Lewis G, Hunot V. Psychodynamic therapies versus other psychological therapies for depression. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD008706. DOI: 10.1002/14651858.CD008706. Accessed 12 May 2026.

8:  Høglend P. Exploration of the patient-therapist relationship in psychotherapy. Am J Psychiatry. 2014 Oct;171(10):1056-66. doi: 10.1176/appi.ajp.2014.14010121. PMID: 25017093.

9:  Nakamura K, Iwakabe S, Heim N. Connecting in-session corrective emotional experiences with postsession therapeutic changes: A systematic case study. Psychotherapy (Chic). 2022 Mar;59(1):63-73. doi: 10.1037/pst0000369. Epub 2021 Jul 22. PMID: 34291996.

10:  Abbass AA, Kisely SR, Town JM, Leichsenring F, Driessen E, De Maat S, Gerber A, Dekker J, Rabung S, Rusalovska S, Crowe E. Short‐term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No.: CD004687. DOI: 10.1002/14651858.CD004687.pub4. Accessed 12 May 2026.

11:  Perry JC, Bond M. Change in defense mechanisms during long-term dynamic psychotherapy and five-year outcome. Am J Psychiatry. 2012 Sep;169(9):916-25. doi: 10.1176/appi.ajp.2012.11091403. PMID: 22885667.

12: Babl A, Grosse Holtforth M, Perry JC, Schneider N, Dommann E, Heer S, Stähli A, Aeschbacher N, Eggel M, Eggenberg J, Sonntag M, Berger T, Caspar F. Comparison and change of defense mechanisms over the course of psychotherapy in patients with depression or anxiety disorder: Evidence from a randomized controlled trial. J Affect Disord. 2019 Jun 1;252:212-220. doi: 10.1016/j.jad.2019.04.021. Epub 2019 Apr 8. PMID: 30986736.

13:   Yakeley J. Psychoanalysis in modern mental health practice. Lancet Psychiatry. 2018 May;5(5):443-450. doi: 10.1016/S2215-0366(18)30052-X. Epub 2018 Mar 21. PMID: 29574047.

14:  Blatt SJ, Behrends RS. Internalization, separation-individuation, and the nature of therapeutic action. Int J Psychoanal. 1987;68 ( Pt 2):279-97. PMID: 3583573.

Medical Reasoning vs. A Diagnostic Manual

 

I taught a course on medical decision making and how not to mistake a physical illness for a psychiatric disorder from about 1990 to 2002. The main theorists at the time were all internists – Stephen Pauker, Jerome Kassirer, Richard Kopelman, David Eddy, and Harold Sox.  I read their papers and attended their courses.  State-of-the-art in those days involved extensive differential diagnosis, Bayesian analysis, and an awareness of an extensive list of potential cognitive biases. I had been impressed with the need for pattern matching and pattern completion and incorporated all those elements into my course.  I eventually pared it down to about 9 sections in the lecture notes illustrated with case vignettes.

My original emphasis was to recognize that there are several considerations when assessing the medical aspects of psychiatric care.  The first is the medical stability of the patient.  Can they be cared for on a psychiatric unit or do their medical needs require medicine or in some cases surgery?  Do they need referral to a generalist of specialist?  This is more complicated than it sounds because the patient is there seeing a psychiatrist for what is supposed to be a psychiatric problem.  But that presentation is complicated by several factors including most patients have no primary care physician and no routine health care maintenance. Many will come into the emergency department concerned about a medical problem but get sent to psychiatry. In that situation, people still get all of the acute medical illnesses including heart attacks, strokes, asthma attacks, pulmonary emboli, seizures, pneumonia, meningitis, encephalitis, and acute cholecystitis to name a few.  Many exhibit non-specific behaviors like agitation, crying out, aggression, or unresponsiveness that can be due to either a psychiatric disorder or a medical problem.    

The second is a psychiatric presentation of a physical illness in a communicating patient. The classic presentations involve brain pathology that is infection, inflammatory, vascular, trauma, or neurodegenerative.  Systemic endocrinopathies and inflammatory disorders are a close second. 

Finally, there is the patient with a clear psychiatric disorder who has intercurrent illness that is or is not known.  Examples that I have seen many times include current or new onset diabetes mellitus, profound anemia usually secondary to an upper or lower GI bleed, dermatology conditions that have often been neglected, symptomatic nutritional deficiencies (B12, folate, D), sexually transmitted diseases, complications of substance use like cirrhosis, and various acute and chronic infectious diseases.

Given that large population with diverse medical and psychiatric problems as well as diverse presentations that can include denying any physical problems – I typically reviewed how the diagnoses occurred.  Pattern matching was the fastest.  The physician has seen a physical finding, lab, behavior, etc – many times before, knows what it is, diagnoses it and treats it.  A good example is a rash.  Dermatologists are rash experts and can correctly classify rashes and marginal cases much faster than primary care physicians (4).  The same is true for diabetic retinopathy and ophthalmologists (5).  Until you have seen a person with severe mania or catatonia, neuroleptic malignant syndrome, or serotonin syndrome it is less likely that you can diagnose the conditions by reading criteria in a book.  Patterns are important for all medical specialists.

On the other end of the spectrum is the contemplative side of diagnosis.  There are several possible diagnoses, and it takes additional data, thought, and reasoning to come to a final diagnosis. Every medical student does this in their initial internal medicine rotation.  There is encouragement to produce a list of many diagnoses that might account for the presentation – but even as the case is being recorded or presented that list rapidly narrows to the apparent diagnosis.

In psychiatry, it may take much more data and collateral information to make a specific diagnosis at the initial presentation.  First episode psychosis (FEP) is a case in point. It is very important to determine what the symptoms onset was like and whether there were any associated mood symptoms or substance use problems. The patient may not be able to describe the phenomenology and depending on the circumstances treatment may be initiated while the diagnostic process is ongoing.  Teaching about the diagnostic process, we would spend time discussing what that might look like combined with a recursive approach to the patient and an awareness of cognitive and emotional biases.  I provided several examples of non-psychiatric physicians making errors due to emotional biases.

Since my course, the literature on medical decision making has changed to some degree.  There is some literature that addresses expertise in general at both the level of cognitive psychology (1) and neurobiology (2).  The general approaches have been to analyze expertise and diagnostic reasoning from the perspective of typical domains (cognitive, perceptual, motor) or to look at a general model and how that has developed over the years.

A dual processing model (3) is generally considered the best current representation of clinical reasoning and decision making.  In this model, there is a fast automatic, heuristic, and unconscious system called Type 1 and a slower conscious, analytical, and effortful system called Type 2.  Additional properties are indicated in the following table.

Parameter	Type 1	Type 2
Speed	Fast, automatic, unconscious/preconscious, little effort	Slow, deliberate, analytical, varying degrees of effort
Control	Minimum control, similar to automatic associations in everyday life except more focused	Control over thought process and direction
Systems and Processing	Pattern recognition and completion, implicit learning, access to long term memory	Working memory and manipulation of data in working memory, planning and reasoning based on that data
Memory Systems	Long term memory	Short term and working memory
Localization	-Orbitofrontal cortex (OFC) -Basal ganglia (caudate, putamen) -Insula -Anterior cingulate cortex -Amygdala -Hippocampus	-Dorsolateral prefrontal cortex (DLPFC) -Left inferior frontal gyrus -Middle frontal gyrus -Inferior parietal lobule -Precuneus -Hippocampus

 A clinical example of Type 1 reasoning is when a trained clinician recognizes a classic presentation of a medical illness, diagnosis, or finding.  An example I frequently use is when one of my Infectious Disease attendings who was an expert in Streptococcal infections recognized characteristic rash from across the room on a patient we were consulted for a different problem.  He made the diagnosis within seconds and told us how it could be confirmed.  In studies of the process the orbitofrontal cortex and limbic connections are activated.  Training is a critical element, especially seeing a maximum number of patterns and their variations.  Although the characterization is that this is a fast and automatic process, there is some room for deliberation.  For example, recognizing or attempting to classify equivocal cases without classic presentations. 

Type 2 reasoning is considered more of the typical process of differential diagnosis.  The findings are compared, analyzed, and accepted or rejected based on additional data and clinical judgment. This process is thought to localize in dorsolateral prefrontal cortex (DLPFC) the home of the working memory where data can be maintained and analyzed.  The left inferior frontal gyrus contributes to rule-based reasoning and hypothesis testing.  A clinical example from my experience is the case of the agitated stuporous patient.  These cases require a great deal of caution because they are most likely to represent a serious or life-threatening illness.  It requires a clinician who knows how to examine patients with stupor or coma and rapidly makes sense of the history and findings. It is a problem that can rarely be solved by Type 1 reasoning alone due to a fairly non-specific presentation.  Some of the critical points for hypothesis testing will be signs of increased intracranial pressure, purposeful response to painful stimuli, eye movements, reflex and musculoskeletal exam abnormalities, signs of infection, and meningeal signs.

The interaction between Type 1 and Type 2 systems is not necessarily sequential but it can be with the Type 1 system matching patterns that lead to hypothesis generation.  There is some evidence that in most clinical situations most of the diagnoses occur with Type 1 reasoning.  Experts can operate at the level of Type 1 reasoning due to extensive experience.  There is not necessarily a hard separation based on the properties in the table. Some hypothesis testing can occur at both levels.  Both systems are commonly grounded in both the limbic system and the hippocampus.

The human brain is capable of parallel distributed processing of data or information.  This means that there are many processing areas in the brain that are interconnected and they can all be working at once.  The modern conceptualization is brain networks that are active processing areas connected by white matter tracts widely distributed through the brain.  

That brings me to my model of diagnostic reasoning (see lead graphic and click to enlarge).  It is based on the course I taught, neuroanatomy and neurology, and what I have observed clinically. When I was talking about pattern matching 20 years ago based on my observations and reading studies in dermatology, ophthalmology, radiology, and pathology – the term seemed to fade rapidly from the diagnostic reasoning literature.  It was revived somewhat by the more recent focus on AI and comparison of that modality to humans.

There was a lull in Bayesian analysis after the invention of computerized programs like Quick Medical Reference (QMR) and Iliad.  They were designed to facilitate medical diagnoses by providing an exhaustive list of findings and their probabilities. These were 20^th century personal computer programs and not AI.  A study of these and 2 additional programs suggests that the programs got 52-71% of 105 diagnostic cases correct with 19-37% being the mean portion of correct diagnoses (6). Despite those figures the programs provided an additional 2 diagnoses per case that experts considered as relevant.  The authors recommended that the programs be used only by physicians who could include the relevant and exclude the irrelevant information provided by the programs.  The programs were discontinued without further modification or updates.  

That is the 8-mile-high view.  I plan to do a deeper dive into the neuroanatomy and neurophysiology.  But the clear reality of the situation is the ability to make a psychiatric diagnosis resides in the brain of a psychiatrist and not a classification manual or a checklist.   Manuals and checklists are crude approximations of some of the cognitive features that psychiatric experts possess.  Like all experts – skill will vary based on practice, exposure, and interest because of the effects on these brain systems.  But we are well past the point of equating what a psychiatrist does to a crude manual.  A manual never saved or treated anyone.  Further – the diagnostic reasoning process emphasizes elements that are important for education and training. It seems that in the past decades there has been a preoccupation with evidence-based research rather than the evidence itself. It does not do the physician or patient any good to be in a situation where that physician is unable to communicate with a person who is in a critical state and has no idea how to assess that problem.  Rearranging diagnostic criteria in a manual for the ninth or tenth time does not get you there.   

 

George Dawson, MD, DFAPA

Supplementary 1:   Before anyone says the diagram is too complex - it is a general diagram for any human diagnostician.  The main modifications for physicians and psychiatrists are the interactive aspects that include empathic comments, formulations, and numerous verbal interventions that other diagnosticians may not need to use.  The specifics about how these memory systems interact are not known at this point - I will be researching that over the next several months.  I borrowed the superposition concept from quantum mechanics - even though there are no wave functions for memory.         

 References:

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1:  Bilalić M.  The Neuroscience of Expertise.  Cambridge University Press. Cambridge, United Kingdom. 2017.

2:  Maguire EA, Gadian DG, Johnsrude IS, Good CD, Ashburner J,  Frackowiak RSJ, Frith CD. 2000. Navigation-related structural change in the hippocampi of taxi drivers. Proc Natl Acad Sci USA 97:4398–4403.

3:  Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking. Acad Med. 2017 Jan;92(1):23-30. doi: 10.1097/ACM.0000000000001421. PMID: 27782919.

4:  Federman DG, Concato J, Kirsner RS. Comparison of dermatologic diagnoses by primary care practitioners and dermatologists. A review of the literature. Arch Fam Med. 1999 Mar-Apr;8(2):170-2. doi: 10.1001/archfami.8.2.170. PMID: 10101989

5:  Sussman EJ, Tsiaras WG, Soper KA. Diagnosis of Diabetic Eye Disease. JAMA. 1982;247(23):3231–3234. doi:10.1001/jama.1982.03320480047025

6:  Berner ES, Webster GD, Shugerman AA, Jackson JR, Algina J, Baker AL, Ball EV, Cobbs CG, Dennis VW, Frenkel EP, et al. Performance of four computer-based diagnostic systems. N Engl J Med. 1994 Jun 23;330(25):1792-6. doi: 10.1056/NEJM199406233302506. PMID: 8190157.

The Reality of Mental Illness is Much More Than Stigma

 

The reality of mental illness is much more than stigma.

It was a simple enough exercise.  Take about 90 seconds and say how mental illness affected you or your family.  Do it in groups of six and when I say time is up - move on to the next person.  The exercise was suggested by a conference speaker who said a similar disclosure during an interview had given him cause for concern about stigma.  The setting was a psychiatry meeting focused on stigma and we had all spent the morning listening to presentations on the topic. 

I really don’t like any professional meeting that resembles an encounter group and think it should be actively discouraged.  I think most people are like me – they go to professional meetings to hear experts and passively absorb information.  Further - I had just commented on the psychodynamics of shame a few weeks ago in the seminar that I coteach and defined the emotion has origins in disclosing information that could be embarrassing or that others would potentially criticize you for.  Of the 5 other people at my table – I knew one professionally and had just met two.  I was the oldest person (by 30 years) and the only man.  When they asked for a volunteer to start – I volunteered.  I did not think there could be a more severe story, was thoroughly habituated to telling it over the past 50 years, and knew that 90 seconds was not nearly enough time to describe how bad it really was.  I was right on all three counts.

“When I was 16 – I woke up one morning, went downstairs, and found my father dead.  Sometime after that my mother began to have severe episodes of mania. During these periods she disrupted the lives of various people in town to the point that police were called repeatedly.  After several police calls, she was taken to a state hospital where she usually spent a few months until she was stabilized and came home.  The manic episodes usually happened around Christmas time.  I was the oldest of 5 children so I tried to keep things together.  One-time things got so bad my brother and I had to call the police ourselves and they came down and told us that we wanted her ‘locked up like a chicken in a chicken coop’. When I was a kid, I was not ashamed about the situation – I was pissed off.”

Time was up.  I was not excessively emotional about what I just said – but realized it was a very sanitized version.   I did not describe the symptoms – extreme paranoia, irritability, impaired judgment, and anger.  The disruption usually involved telephone calls to public officials or the local radio station when she would announce her name and begin swearing at whoever was on the other end of the phone. At times she would get very angry and carry a knife around suggesting that we should stab her with it.  She would throw us out in the middle of winter.  We would come home from school and find that she had thrown all of our clothing out of an upstairs window and we had to pick it up off the ground.  We would find strangers at dinner or once - sleeping in the bathtub.  At night when we tried to sleep, she would play the stereo loudly all night long – usually Danny Davis and the Nashville Brass Christmas album – punctuated by screaming up the stairway at us.  It was hard to get up and go to school the next day after one of those nights.

On a road trip – my wife and I stopped in to see her.  The floor in the house was covered in about 6 inches of debris (from emptied drawers and closets).  She would throw a dash of Galliano onto the piles. She was making bizarre statements while circling the mouth of a hot jar of peanut butter with a piece of celery and then throwing the molten peanut butter over her shoulder.  My wife was upset and had to leave.  She sobbed for the next half hour as we travelled down the road telling me she was sorry for what I had to endure as a teenager.   

Even if I had time to add this additional information, that only scratches the surface of my mother’s experience with severe mental illness and the impact on the family.  I could write a book about what happened.  I am including it here just to illustrate the severity of the problem. These symptoms typically lasted for many months and some eventually became chronic.  As a psychiatrist – I have no illusions that her symptoms were anything but the product of a severe mental illness that was not treated well.  Her primary care physicians at the time were using a combination of amitriptyline and chlordiazepoxide – medications that psychiatrists would not use – even back then.  She eventually had access to a psychiatrist and was given lithium but it was not very effective.   

Stigma was not the main problem.  The main problem is that when a person has a severe mental illness like my mother it disrupts the relationship you have with them, That disruption is more severe when you are a kid and can’t make sense of it. It can affect your development and self-image.  The broken relationship can be permanent.  It is more like grief and loss rather than stigma and shame.  After a while my mother was not the same person any more. I no longer recognized her.  I could not remember what she was like before the onset of severe bipolar disorder.  I don’t think anybody did.  It had a more severe impact on my mother than anybody – but the emotional and interpersonal impact on everybody else was undeniable. 

All of the discussions of psychiatric diagnosis and treatment do not touch on that.  The bizarre discussions of antipsychiatrists and philosophers don’t even come close.  If you are saying that my mother was not mentally ill or did not have a “natural kind” of illness – you do not know what you are talking about.   If you are suggesting that she needed “trauma informed care” – not much better.  The unexpected death of her 43-year-old husband was certainly stressful, but the expected reaction is not decades of severe bipolar disorder.  It is bereavement, a universal experience, and all that involves. The lack of psychiatric care early in the course of illness could certainly have been a factor.  Her care rarely involved any of the family.  I don’t think any of her physicians knew how severe that impact was.  Despite the fact that she lived in the state where Assertive Community Treatment (ACT) was invented in the 1970s – it was a rural county and active outreach by case managers was decades away. 

My mother’s siblings and parents were very supportive. It would have been very difficult to have made it through many of these episodes without them.  It took an emotional toll on all of them as they tried to reason with her and convince her to do the right thing – like curbing excessive spending and trying to get some sleep.  The female members of the family – my grandmother and aunt were much more effective than the men.  They were able to react at a level that was not strictly emotional.  My siblings who remained in town or returned also had a stabilizing effect.  She had two very supportive female neighbors who spent hours talking with her despite the obvious problems.  But even with all of those efforts - my mother was never restored to her baseline.  Recovery to baseline was a goal I eventually adopted with every person I saw as a psychiatrist.    

What seems like a good interactive exercise to make a point about stigma is a very blunt instrument.  There is no doubt that some of the local officials discriminated against her (and us) because of the stigma of severe mental illness.  That was not close to universal by any means.  At a recent reunion I greeted a retired police officer who was very helpful to our family with his advice and reassurance.  He did everything possible to avoid confrontations with my mother when she was confrontational.  I never got the chance to thank the women in our neighborhood who helped but did when I sought them out in a crisis.  

Stigma can be an important factor – but the take home message from this essay is that the overwhelming fact about severe mental illness is the illness itself.  It has a significant emotional impact on everyone.  It disrupts interpersonal relationships – some of them permanently.   Some of that can be grieving the loss of a person who is never coming back.  It produces progressive isolation and alienation of the person with the illness. It is used rhetorically at the political level - blaming people with mental illness for violence and other ills of society.  In the current context treatment resources are being removed at the same time and that is probably the biggest societal ill.

At the rhetorical level stigma is also confused or conflated with clinical psychiatry. The ultimate societal outcomes of stigma are labelling and stereotyping to define the socially undesirable group.  Much of the rhetoric aimed at psychiatry promotes this fallacy.  Psychiatry operates at the level of disease reality.  The same level that affected my mother and my family.         

The reality of mental illness is much more than stigma.

George Dawson, MD, DFAPA.  

Supplementary 1:   I posted this about 10 years ago on stigma.  If you use the search box on the front page of this blog there are about 15 additional posts where I mention the term in one context or another.  Since then, the jargon has advanced to define separate types of stigma.  Per this CDC web page they define three types with their suggestions for combating it.      

 

Mental health stigma can take many forms (CDC)

• Structural stigma, involving laws, regulations, and policies that can limit the rights of those with mental health conditions.3
• Public stigma, which include negative attitudes and beliefs from individuals or from larger groups towards people with mental health conditions, or their families or health care providers that care for them.3
• Self-stigma, which comes from within the person with a mental health condition.3 People living with a mental health condition may believe they are flawed or blame themselves for having the condition.4

These definitions leave out important dimensions.  For example – where are the insurance companies, managed care industry, pharmaceutical benefit managers, and governments that limit mental health coverage and treatment resources like psychiatric beds?  At the same conference I attended one of the advocates talking about the state government no longer funding an important clubhouse resource for people with mental illness. 

The public stigma is devoid of the politics that defines people with mental illnesses either as violent criminals or freeloaders getting benefits that they are not entitled to. If you really want to cancel that stigma why not clearly identify where it comes from?

Self-stigma seems to be describing self-image, self, and self-esteem concepts that most psychotherapy providers learn how to address in that process.  

For all of these reasons the stigma seems to be a rhetorical stretch to me.  If you want to address these issues point to the source of the discrimination and don’t make it into a general societal issue.  It is a societal issue only at the level that society never confronts the real source of discrimination. 

Supplementary 2:  Self disclosure is generally discouraged in psychiatry.  If you are practicing it may lead to speculation about your personality, biases, or style of practice.  In the case of this exercise it was encouraged even though there were no assurances of confidentiality and no therapeutic intent.  It was clearly an exercise to illustrate a point that could have as easily been made with a thought experiment.  In this case my mother has been deceased for 22 years. My limited discussion of her illness is done here to illustrate the reality of severe bipolar disorder and the associated effects compared with the issue of stigma.          

3 Million Reads

 

I crossed over 3 million reads on this blog sometime around 10 AM this morning.  I check the counter a couple of times per day and the number was 3,000,423 at a current rate of about 150K per month.  Earlier this month I confirmed with the host that this number represented actual pages downloaded and read and it does.  The Google Blogger site that I use seems to underrepresent individual page reads but the aggregate count is still good.  My speculation is that this has to do with a more widespread adoption of VPNs but have no confirmation of that.

In terms of an accomplishment – blogging is a mixed bag.  I always approached my work like I was a researcher in addition to being a physician.  That involved an enormous amount of additional reading and research. At the same time, it conflicted with my primary role as a clinician and it really conflicted with my role as an employee.  When I say conflicted, there were basically two spheres.  First, the time constraint.  Luckily, I had chronic insomnia so I could spend the time not sleeping by doing research and reading.  Second, the lack of time to do formal research and write papers.  The research I did was on a case-by-case basis and to teach courses to medical students, graduate students, and physicians.  I came very close to working with a world class research team prior to retirement – but was with them for only a couple of years.  It did give me a glimpse into what would have been possible.

From a historical perspective, it also speaks to how information is disseminated in the modern age.  Herman Melville lived from 1819-1891.  He wrote Moby Dick a book considered to be one of the greatest novels of all time and yet only 3,000 copies were published during his lifetime.  I know this blog is certainly not Moby Dick – but it speaks to what is currently possible and the range of quality writing and in many cases overt misinformation that is now published for free and open to all of the public.  

It took a while to figure out my approach.  In the Pages section of this blog (upper right corner of the main page) I briefly discuss the how and why I write this.  At this point it is basically a continuation of my work life into retirement. When you have done something almost all of your adult life it is both difficult and unnecessary to stop it.  It also provides a perspective to analyze other problems and areas of life like art and politics. By perspective I am talking about a way of thinking rather than diagnosing. The only people I diagnose are the ones sitting across from me in an office who come in to see me as a psychiatrist.     

I get emails from psychiatrists and other health care professionals from around the world.  Some of these folks are quite renowned.  Some are critical because they disagree with my viewpoints, but most of them are interesting and have similar observations.  Early on I made the mistake of publishing remarks that were not only highly critical but personal attacks.  Since adopting a no trolls policy things have been going a lot more smoothly.  It was interesting that in 30 years of Internet discussions I adopted that policy 20 years ago in discussions but it took me a lot longer on this blog.  I attribute that to an unconscious wish for acceptance.

At this point I have a lot of things in the pipeline including a discussion of Margaret Atwood’s work, discussion of a paper on involuntary treatment that involves pseudorandomization, involuntary treatment for substance use disorders, the ongoing psychiatric hospital bed shortage and a Scandinavian study that looked at correlates of suicide and beds, a book review of Psychiatric Neurology, and much more.  I find that I have to work on several things at once to avoid writer’s block.  I am also working on a chemistry and physics perspective that I think adds to the dimension of spirituality and just received a book about how elements that we are all composed of are formed in stars.

I recently celebrated the milestone of one year volunteering as a co-instructor in a weekly 2 hour seminar on psychodynamic psychotherapy for psychiatric residents.  That has led me to think about areas of life and psychiatry that I would not have without that participation.  I am grateful to my co-instructors and the residents in that seminar for stimulating discussions and emails.  I am quite willing to volunteer for other academic projects – either teaching or research.

That is where things stand today.  I am grateful for the reads and comments and plan to keep writing this blog into the future whether I get to the 4M mark or not.

 

George Dawson, MD, DLFAPA        

Two million reads was almost exactly 2 years ago:  https://real-psychiatry.blogspot.com/2024/03/a-million-reads-blogging-milestone-of.html