Door County Summer Institute #33

The Door County Summer Institute (DCSI) was founded by Medical College of Wisconsin Professor Carlyle H. Chan, MD.  It is held at the Landmark Lodge in Egg Harbor, Wisconsin.  Egg Harbor is one of many small towns that dot the Door County peninsula bordered on the west by Green Bay and on the east by Lake Michigan.  If you have a lake view from the Lodge, there is generally an unobstructed view of the expanse of Green Bay with a few visible islands on the horizon. The weather this time of the year is tropical for the midwest with temperatures in the 80s and the occasional thunderstorm.

The DCSI is a psychiatry conference and most of the people who attend are psychiatrists but there are also psychologists, social workers, NPs, PA-Cs and nonpsychiatrist physicians.  The programs are very eclectic with topics ranging from psychopharmacology to terrorism. In the course I have attended there have been 1 to 3 instructors.  The instructors are all generally considered to be experts in the fields they are presenting. The courses are generally 2 days in duration (mornings only) with plenty of discussion about places to see in the area that include, restaurants, art galleries, concerts, plays, and musical productions.

As I mentioned in a previous post, I attended four sessions on Practical Neuropsychiatry for Clinicians presented by Sheldon Benjamin, MD.  I consider myself to be a neuropsychiatrist.  Early in my career, I attended behavioral neurology conferences and ran an Alzheimer's Disease and Memory Disorder Clinic co-staffed by a neurologist for about 12 years. I also evaluated neuropsychiatric problems in acute care settings. My hope was to get some complementary knowledge from an expert with a different career path and I was not disappointed.

The first session was spent on an overall neuropsychiatric approach to the patient and Dr. Benjamin made the observation that neuropsychiatry is personalized medicine in that each formulation is uniquely developed for the individual and it also answers the question about what treatment will help that unique individual. On that basis, is is not a nonspecific label.  His reasoning can be extended to the psychiatric formulation in general. As previously noted on this blog, a formulation is the most unique aspect of the evaluation and it needs to be included as well as the diagnoses. Any psychiatrist knows that people with the same diagnoses are unique individuals and that the diagnosis alone does not take into account the unique conscious states of individuals any more than any other medical diagnosis.

From there most of the rest of the first day was spent on a discussion of frontal lobe function and executive function.  Rather than focus on the consensus list of neuropsychological tests thought to comprise executive function, he presented an adaptation of D. Frank Benson's schema to illustrate the basic dimensions (anticipation, monitoring) involved in goal selection and planning and the underlying behaviors.   He emphasized the assessment of frontal function as being possible without any specialized testing and illustrated the point with a humorous example (1).  Executive function was primarily a product of prefrontal cortical function but parietal cortex and cerebellar cortex were also involved on the basis of an analysis of cognitive and neuroimaging articles (2).

There was an emphasis on practical assessment frontal lobe function and more specifically the ecological validity of the tasks. In other words what do the tests mean in real life. The MoCA Test was used to illustrate that tests of frontal executive function do not require any special equipment. The trail making, clock drawing, and verbal fluency sections were highlighted as requiring frontal executive function. The MoCA Test was described as potentially problematic due to the new licensing procedure. Dr. Benjamin presented several other tests that could be added to the bedside exam that included both neurological examinations of for example anti-saccades and more complex cognitive tasks such as complex problem-solving, inferential reasoning, the script generation task, and a headline task. After the presentation there was a brief workshop where patient was presented and participants needed to pick one behavioral problem, develop a hypothesis, and suggest what tests could be used.  The ultimate goal was to consider not just a useful test, but also potential rehabilitation approaches. A total of 16 cognitive domains and 30 cognitive tasks were provided that could be used to develop specific tests.

The final section of the first two days was about traumatic brain injuries.  I have a previous post on an application from this section on classifying the severity of these injuries.  The epidemiology is striking with a prevalence equivalent to patients with severe mental illnesses.  The death rate is about 50,000 people per year and at 1 year a many as 15% of people with a mild TBI remain symptomatic.  The myth discussed is that we all grow up thinking that TBIs are relatively benign.  I see that occurring regularly in the patients I assess who have had multiple TBIs or concussions and who never saw a physician for assessment. In many cases they resumed playing the sport immediately where they were injured.  That is a very high-risk scenario.  The coupe-contre-coup injury was discussed as well as how to identify it on brain imaging studies and autopsies.  Several specific mechanisms of injury were discussed including diffuse axonal injury (DAI) and how that occurs during TBIs.  Shear forces used to be considered the main mechanism of injury but now permeability changes are thought to occur that leads to lysis of axons in the 12-24 hour window.

Second Syndrome or Second Impact Syndrome was mentioned as a complication of returning to play too soon and sustaining a second concussion with a resulting massive injury.  It apparently based on a 1984 report (3) where a football player sustained a concussion in a fight and then another concussion 4 days later playing football.  That second injury resulted in massive cerebral edema and death. The purported mechanism is a vulnerable window of decreased brain metabolism.  Concussed athletes have been examined with MR spectroscopy.  In this method, N-acetylaspartate (NAA) is a marker of neuronal viability. Following concussions, NAA is depressed to the lowest at about three days after the injury and it recovers by 30 days.  In another study, if a second injury occurred before 15 days – recover of the NAA marker did not occur until 45 days.  Some sources consider this syndrome to be controversial due to recall bias and a lack of reported cases in other literature, but the depression of brain metabolism is concerning.  Clinical symptoms of TBI may be underreported or not reported at all during this recovery phase.

In the section on specific frontal syndromes, Dr. Benjamin pointed out that he was pleasantly surprised by the Neurocognitive Disorders section in the DSM-5.  I agree with his observation. There is highly detailed information about making those diagnoses and what information is relevant. For the course he looked at personality changes associated with various frontal syndromes such as orbitofrontal syndrome, prefrontal syndromes, mixed frontal syndromes, ventromedial syndromes, and secondary mood disorders.

That last two days of the course were focused on memory, encephalitis lethargica, autoimmune syndromes, and the six landmark cases necessary for neuropsychiatric literacy.  I will end with a summary of the six cases because for most readers of this blog – they are readily accessible in the paper written by Benjamin, et al (4).  His discussion of the Phineas Gage case was remarkable given the amount of misinformation that exists.  He presented a detailed timeline of the injury and how Gage was treated initially by the town physician and then by the railroad physician.  New England Journal of Medicine subscribers may be surprised to learn that they have access to the full text of an 1848 account from attending physician Dr. Harlow (5).  There are 43 references in the medical literature. For anyone not familiar with the case, he sustained a penetrating wound to the brain when a 43 inch, 13.5 pound iron rod used to tamp sand and gunpowder into a hole for excavating rock was propelled through his left orbit and left frontal lobe exiting out the top of his skull.  Dr. Benjamin pointed out that there are numerous false accounts of the incident and I had read several suggesting that the rod had to be extracted from Gage's skull by the doctor in attendance. In fact, the rod blew through his head an landed about 30 feet away.  The rod had been specially designed by Gage so that one end was tapered for prying.  That is what led to the penetrating wound and is also what saved him.  The year of this injury was 1848, before antibiotics and neurosurgery.  Gage was transported to a hotel where he stayed and was able to walk up to his room on the second floor where he experienced transient delirium but he was able to recover and return home after 74 days.  There are numerous accounts of his neuropsychiatric recovery.  The commonest description is that he was "no longer Gage".  He could no longer work as a railroad foreman, but sometime later traveled to Chile where he was a stagecoach driver managing a 6-horse stagecoach. He died about 12 years after the injury from status epilepticus.  The index case of severe frontal lobe damage illustrates preservation of cognitive and motor skills with some personality changes.        

  

 In conclusion, I highly recommend Dr. Benjamin’s work and this course if you ever want to attend a DCSI.  More to the point, I highly recommend that medically oriented psychiatrists develop skills in neuropsychiatry by working these principles and skills into their practice like I have over the past 30 years.  When I say medically oriented psychiatrists, I am generally referring to acute care psychiatrists (inpatient, addiction and consultation liaison) and outpatient psychiatrists who are seeing patients as identified as having cognitive problems and possible dementias like geriatric psychiatrists or psychiatrists who specialize in treating people with complex medical and psychiatric problems. In my situation seeing inpatients with a variety of complex problems, making associated medical diagnoses, and working closely with other consultants was very effective in reaching this goal. An additional skill was reading all brain imaging and taking an early interest in EEG and QEEG.  Seeing all of the brain imaging of patients has never been easier than with the current EHR.  When we were using only paper records, I would often trace an axial section of a CT or MRI and put that in the patient’s chart but now it is right there.   I think it is also a critical factor in deciding what an ultimate practice environment must look like for psychiatrists interested in this type of practice. Th environment has to provide access to the necessary imaging, neurophysiological, and laboratory testing as well as easy access to other consultants.  Complex problems require an environment where they can be addressed.  Many current practice environments for psychiatrists do not provide access to these tools or state-of-the-art treatment modalities.  In many of these settings it is difficult to find a working blood pressure device. 

Given the appropriate medical setting, there has never been a better time to be a neuropsychiatrist and train neuropsychiatrists for the future.

George Dawson, MD, DFAPA

References:

1: Rockwood K, Chertkow H. A cellular-telephone model of assessing frontal lobe function in physicians. CMAJ. 2007 Dec 4;177(12):1533-5. PubMed PMID: 18056616. Link (full text)

2: Nowrangi MA, Lyketsos C, Rao V, Munro CA. Systematic review of neuroimaging correlates of executive functioning: converging evidence from different clinical populations. J Neuropsychiatry Clin Neurosci. 2014 Apr 1;26(2):114-25. doi: 10.1176/appi.neuropsych.12070176. Review. PubMed PMID: 24763759. Link (full text)

3: Kamins J, Giza CC. Concussion-Mild Traumatic Brain Injury: Recoverable Injury with Potential for Serious Sequelae. Neurosurg Clin N Am. 2016 Oct;27(4):441-52. doi: 10.1016/j.nec.2016.05.005. Review. PubMed PMID: 27637394; PubMed Central PMCID: PMC5899515. Full Text

4: Benjamin S, MacGillivray L, Schildkrout B, Cohen-Oram A, Lauterbach MD, Levin LL. Six Landmark Case Reports Essential for Neuropsychiatric Literacy. J Neuropsychiatry Clin Neurosci. 2018 Fall;30(4):279-290. doi: 10.1176/appi.neuropsych.18020027. Epub 2018 Aug 24. PubMed PMID: 30141725.

5. Harlow JM.  Passage of an Iron Bar Through the Head. The Boston Medical and Surgical Journal. 1848 XXIX(20): 389-393.

6: Damasio H, Grabowski T, Frank R, Galaburda AM, Damasio AR. The return of Phineas Gage: clues about the brain from the skull of a famous patient. Science. 1994 May 20;264(5162):1102-5. Erratum in: Science 1994 Aug 26;265(5176):1159. PubMed PMID: 8178168.

7: Haas LF. Phineas Gage and the science of brain localisation. J Neurol Neurosurg Psychiatry. 2001 Dec;71(6):761. PubMed PMID: 11723197; PubMed Central PMCID: PMC1737620. Full Text

Supplementary 1:

Don’t forget Dr. Benjamin’s Brain Card as an excellent resource.  The nominal cots is used to fund a web site that provides free access to additional clinical resources that are available to Brain Card holders for free.

Supplementary 2:

I anticipate some complaints from psychiatrists who will say that they do not have enough time to do detailed assessments like the ones suggested in this post.  Despite the penetration of managed care and the fact that most physicians are employees, I contend that it is still possible to do detailed and intensive evaluations on patients with complex problems. My strategy for a long time was to do inpatient work where I could see people as many times a day as I needed to an I had access to resources like EEG labs and imaging studies.  The ability to meet with families for a more in depth analysis of the problem was also a plus. Choosing the correct work setting goes a long way toward allowing this kind of work.  

The Last High School Reunion

I just went to my last high school reunion.  The reunion model in my hometown is apparently changing so that graduates from all years will meet every 5 years - rather than just meeting with your specific class cohort.  Reunions have a lot of stereotypes.  Hollywood produces a fairly consistent revenge of the nerds on the cliques that suppressed them theme.  Real life is hardly ever that  clearcut.  I have limited experience with reunions myself.  I went to one other reunion about 20 years ago.  I spent most of the time talking with two of my classmates who were farmers and looked forward to seeing them again.

My high school class was moderate in size by today's standards - 230 people.  Twenty per cent of my classmates have died.  As I looked at that list I was reminded of the first girl that I ever slow danced with in the 8th grade. I was reminded of the girl who had an outstanding sense of humor and who could always make me laugh.  She was always in a good mood and I was always happy to see her.  I was reminded of the guy I was always paired with in gym class for wrestling who was about four times stronger than me and and who could wrap me into a knot. I remembered the girl in my homeroom who was just in front of me in alphabetical order every day when they took attendance.  I remembered the guy who was killed in a fight in college and what a tragedy that was.  I have been thinking about him a lot over the past 48 years.

My association to personally knowing almost everyone on that list is a comment that one of my psychoanalyst supervisors made when I was in training.  He asked me what I thought about learning that someone I knew had died.  I was a very neurotic kid and had significant death anxiety from an early age and my response was: "It could have been me." He told me that I was wrong and gave me what I considered to be a more narcissistic response: "Better him than me!"  Over the decades since, I have tracked that response and most of the time my original response is the first one I think of. But that is complicated when you grow up and mature with a group of people. I know that I was not always at my best in terms of social interactions but I can also recall being bullied and punched and intimidated like most people in school. What happens when you learn of the death of one of your antagonists from middle school or high school?  It turns out to be more complex, but at this point in life it does not matter.  I feel badly about anyone who does not make it to retirement.  I am at the disadvantage of being trained as a psychiatrist - so I don't know what it is like for other people.  Physicians are trained to save lives and psychiatrists are trained further to know that only a relatively primitive person rejoices in the death of another.  But more significantly, even the bullies change over time often to the point that they are not recognizable from their high school behavior.

At the previous reunion that I attended, I walked past a guy who I knew and he knew me. He probably remembered me from high school and all of the associated baggage as well as I remembered him.  We walked past each other several times that night and made eye contact but never spoke. Several years later I was out cycling and decided to pull into the cemetery to see if I could locate my father's headstone.  He would have been dead about 37 years at that point.  I found it and noticed that just to the left was the headstone of a good friend from high school and college.  To the left of that was the guy from the reunion that I never talked to.  His gravestone sat in a field of gravestones with his family name.  I can recall my father talking about people with that family name. Our families were from the same part of town and they did the same kind of work and yet 30 years out of high school there was something lingering there that kept us from acknowledging our common roots. That kind of put things in perspective and I was determined not to let that happen again.

A critical issue is that we know a lot more about human development than we did 30 years ago. I know that as well as anybody both professionally as well as personally.  Looking back on my life in  late high school and early 20 years - I recall feeling like I was in a fog. I could not think very clearly and spent a lot of time daydreaming and fantasizing. I had limited social skills and compensated by avoiding social interactions. The blue collar culture that I was raised in taught me to be suspicious of authority figures - especially politicians and business and union leaders. Some time in my late 20s - I came out of the fog. I would never have guessed that my profession would eventually involve intense interpersonal interactions with people all day long.     

My personal experience starts with the fact that I am an introvert.  It might not come across in the writing on this blog, but conversation with me invariably includes a lot of long pauses unless you are filling in the dead air.  Nobody would consider me charismatic.  I am very comfortable being by myself for long periods of time without social contact.  I don't seek out social contact, and often don't signal people that I am in the area and ready to engage them in conversation. For the past 5-10 years there have been arguments raging about the introversion-extroversion dimension and the relative merits and faults of each.  My real world experience is this dimension really exists but it is more complicated than the stereotypes. For example, introverts are not avoidant and are comfortable in social situations.  They are just not conversationalists and are not engaging. In my case for example, I have no problem at all talking with people all day long about the intimate details of their life.  I have no problems giving hundreds of lectures to medical students, residents, and other physicians.  On the other hand, at a residency graduation celebration - one of my residents came up to me and asked me if I was trying to hide behind the drapes in the ballroom.

The good news is that the reunion went very well. Contrary to the stereotypes, everyone seemed grateful to be there.  Several people had medical and psychiatric close calls that they shared with me.  And I am using close calls the way Carl Sagan did in the Demon Haunted World - without emergency medical or surgical intervention they would not have made it.  Retirement was probably the next most common topic that I discussed with classmates.  The majority of people I talked with were retired, happy to be retired, and either inquisitive about why I am not retired or actively trying to talk me into retiring.  One of the considerations I did not mention to anyone is that I still have not worked as long as they did before they retired (about 35 years) but would be getting there in another couple of years.

The most interesting conversations occurred with people who I have known the longest even though I have not seen them in decades.  We talked about past times, what we had done in the past, and what we planned for the future. I was reminded of the fact that some of these folks knew where I lived as a kid, came over to that house, and did things like play chess and work on models. We did these activities in an odd part of my parents house at the top of a stairway.  Based on what my friends had accomplished, I was reminded that they were bright, creative, and inquisitive people.  They had accomplished a lot and successfully raised families.

On the topic of children and grandchildren - it was clear that the next generation had identified with their parents (my classmates) as evidenced by their vocational choices or choice of hobbies and pass times. Spending time with grandchildren was given as one of the reasons for happiness in retirement.

The physical environment of the reunion was carefully developed by the committee.  The food was buffet style and excellent. Decorations were tasteful and historically meaningful with hippie themes.  This reunion coincided with the 50th anniversary of Woodstock.  There was some barely audible surfer music playing at one point that faded out and no more music was heard.  At the 30th reunion, there was loud disco music at one point and only one couple disco dancing.  I think the committee realized that at 50 years - talking is more important than dancing.

I don't think I have anything profound to say about reunions. anything that I observed there I have seen in life many times before. As people get older,  they are more reasonable. There was some concern about political discussion going into it and an informal ban.  I violated that by talking with a friend who was a political activist until recently - but he said that after years of involvement that he was burned out - much less interested.  Apart from that discussion - politics and other provocative topics were not mentioned at all.  I thought about my prevailing model of a successful society. People just want to work and make it home safely to their families at night.  I saw nothing at my reunion to counter that idea, but it was clear that the retirees maintain a family focus in retirement and do what they can for the next two generations.

Was I successful in countering my introverted tendencies?  I think that I was to a large extent.  I talked to most people that I made eye contact with. I talked to some people more than I probably have to date on that night. I am sure that talking to people on a daily basis for over 30 years has changed me to some extent. My experience at the previous reunion led to a conscious change.  There were probably more opportunities, but at some point there was equilibrium in the room and small groups had formed where people were probably talking with those who they were most comfortable talking with.  I was not perfect by any means.  The room had a view of Lake Superior and a breakwall with a lighthouse on the western end. At one point when the conversation had bogged down - I looked out there and saw a speedboat cruising along the distant side of the breakwall. I watched the boat for a few minutes and projected myself out there and then snapped out of it and came back to reality.

My two farmer friends from the previous reunion never showed up and there were other people that I missed.  Once you have lived a whole life out of high school it seems that those important people go in an out of your life very quickly. A good friend of mine from my class was in town a few months earlier and got my email address from my brother.  When I heard he was looking for me - I tracked him down on LinkedIn and sent him a message.  He was not at the reunion and has not contacted me.

It was a good reunion. I liked being a part of this generation  and some of its subcultures. I was with most of these people in one capacity or another for at least 5 years and and 5 of us were together since kindergarten.  Personality change is gradual even with an early boost from developmental neurobiology.  For me a moderate amount of change has only taken about 50 years. 


George Dawson, MD, DFAPA


Supplementary:  My wife who is an extravert who can talk with anybody gave me high marks for interaction at the reunion.  That is as close to an objective review as I can get.

Mass Shootings Again and Again

There seems to be some optimism that Congress may be more motivated to do something about mass shootings in America given the recent events.  As I have said before - I will believe it when I see it.  Gun control is the prototypical deadlock in the USA, largely due to the effects of the gun lobby and their resistance to common sense gun legislation such as universal background checks, ban on high capacity magazine, and ban on assault weapons.  If anything, the rhetoric in these areas has intensified.  The assault weapons for example are described as not more than semi-automatic weapons just like hunting rifles.  Forget about the fact that the Sandy Hook Elementary shooter fired 154 rounds in 4 minutes from the 10-30 round magazines he  brought with him - killing 26 people 20 of whom were children.  Putting "mass shooting" in the search box in the upper right hand corner of this block will pull up about 14 essays dating back 7 years to 2012 including a proposal to consider violence prevention as a public health intervention.

Another important level of the deadlock is the Supreme Court. Interpretation of the Second Amendment can occur at several levels and in the current Court 5/9 justices are Republican appointees making restrictive gun legislation less likely.  Gun advocates controlled the narrative about the Second Amendment early on so that the preamble is typically ignored.  Gun advocate rhetoric is basically that gun ownership of practically any gun one might want to own is an unconditional right.

Over the years the pattern remains the same.  The issue of mass shooters disrupting American society and killing people is always minimized relative the "rights" of gun owners. The spokespeople on this issue don't even attempt to address the problem. They immediately produce pro-gun rhetoric and maintain that nothing needs to be done.  They are obviously wrong about that.  Mass shootings are the problem.  That is not a gun rights problem or a gang violence problem. It is a problem of keeping guns out of the hands of mass shooters. A secondary public health issue is keeping guns out of the hands of suicidal people. Limiting access is a known solution to both problems. Every reasonable solution should be available to solve that problem including universal background checks and outright bans on weapon types and permanent bans of some people purchasing firearms as well as confiscation and destruction of firearms.

The police response to terroristic threats is instructive. 30 years ago, I received a fax from the local police that a person had purchased a handgun and they were "letting me know" about it.  I called them back immediately and they told me: "We can't do anything because they haven’t done anything yet." Within a few weeks I was personally threatened at home with a handgun concealed under a newspaper and they were planning to use it. Flash forward 20 years and I had a similar threat on my voice mail. I called the police in; they listened to it and told me they were going out to talk to the caller. They called me and said they had talked with him, and that if he contacted me again, they were going to arrest him for terroristic threats. I never heard from him again.

The threshold for police intervention needs to be at least this low for every person identified as a potential threat with access to firearms. Terroristic threats or behavior should be the threshold for police intervention.  In the NICS system persons who have been convicted of misdemeanor domestic violence or subject to a restraining order for harassing, stalking or threatening are prohibited persons and they would fail this federal background check that rejects firearm purchases. In many cases, early signs were noted by members of the public and family members, but it was not clear which authorities should be contacted and how the problem should have been approached.  The protocol for identifying potential mass shooters and the response by the police needs to be standardized and widely applied.  The police response in almost every locality is also a political issue as evidenced by the very gradual adoption of consistent domestic violence laws.

There has been some blurring of boundaries between psychiatrists and the police - most notably by the Tarasoff laws that transfer what I consider to be a police action (warning potential victims) to clinicians.  In many states now, commitment laws are decided by the police since only they are allowed to put people on mental health holds. This is a completely illogical approach to psychiatric emergencies and holds.  There should be a clear division between clinicians and the police.  Clinicians do not take custody of people or discuss confidential information outside of what is legally required and that generally is to specific government authorities and not members of the public.

There have been no public health interventions focused on mass homicide prevention. I have been an advocate for this for a long time. There needs to be a campaign that focuses on anger control and what the resources might be to address it. On acute care psychiatric units, much of what is focused on has to do with the prevention of aggression and violence it has several causes. The message that anger - especially if it involved aggression even to the point of homicidal thinking and planning is a treatable problem and it can be treated before anyone is hurt or that person's life is ruined. Instead of treating it we have allowed mass homicide to persist as a way to express anger in a subculture of largely men. There are many forces in social media reinforcing this inappropriate expression of anger.

Although I have mentioned psychiatric problems here and see violent psychiatric patients as being part of the problem, they are not by any means the major part. I am sure that a personality disorder diagnosis exists in many of these remaining men, but the majority have not had any psychiatric contact. 

Psychiatry in itself will never be a solution to the problem without cultural changes at the level of this violent subculture and their way of expressing their anger and the law enforcement culture seriously resetting the threshold for intervention.  There also has to be a clear intervention to keep highly lethal firearms out of the hands of potential mass shooters. 

Pro-gun rhetoric never addresses that basic point.



George Dawson, MD, DFAPA

Dr. D Gets a Traumatic Brain Injury (TBI)

One of the best illustrations of a psychiatric concept is your own personal observation as a physician.  This really happened to me quite a while ago but even that has implications....

When I was 22 years old I was playing in a football game. It was a city league touch football game. At that point I had probably been playing football in one form or another every day of the year for the previous 10 years.  The typical game was passing 2 on 2 in the street.  In this game, it was across the whole field and I think we had 8 men on the field.  I knew everyone on the team.  On defense, I was a cornerback and on offense -  the quarterback.  In the context of all being 20+ year old men we were all fairly intense.  That probably explains why when a pass was thrown into our defense I ran and dove headlong for the ball.

That was just about the last thing I remember from that day. I can recall glimpses of the fact that I apparently stayed in the game. No recollection of getting my hands on the ball, the impact, breaking my nose, bleeding somewhat, how long I was on the ground, or other plays.  During the dive for the ball, I smashed my face into the shoulder of our other cornerback and was knocked out.  Later he told me his shoulder was sore from the impact. We were both running toward one another at full speed.  A few flashes of standing in the huddle and not responding to questions very well is all that I can recall for the rest of that game.  I made it home.  I vaguely remember an argument where I was asked why I was so irritated. My memory and baseline conscious state didn't come back until until about 2PM the next afternoon in a physical chemistry class.  That was about 18 hours after the game.  At no point was I seen by a physician.

The first question that comes to mind is "Was this a concussion or a traumatic brain injury or both?"  I ask every person I see about head injuries and try to figure out if there was an associated brain injury.  It is one of the most important parts of the psychiatric assessment.  I get a full spectrum of responses from people who say they were knocked out but did not have a concussion to people who had a concussion but were not knocked out to those were in a coma for 5 days or more.

For people of my generation there were two myths that actively interfered with the care of traumatic brain injuries and concussions.  The first was that you could just return to the game.  The number of people I have interviewed who were football or hockey players who tell me they were knocked out multiple times including several times in the same game is shocking.  Returning to the game with a concussion injury or mild TBI is a horrifically bad idea because if another incident occurs it could lead to a devastating brain injury that could be life-threatening.  The second myth is that some players cannot be easily replaced in high school or college. If your star player gets a concussion, the chances that the replacement will not do as good is the difference between winning and losing. The problem with that logic is that the performance of the impaired player has to be seriously deteriorated. On my team, I was certainly not the star but we had no replacements.  That is not the best plan.  To this day, I do not recall the second half of the game but it was not good.  The risk of a life threatening injury is certainly not worth the potential reward of hoping to maintain expected performance to win a game.

What are the current definitions of traumatic brain injury and coma?  I had the opportunity to attend a recent Door County Summer Institute program given by Sheldon Benjamin, MD.  The program was entitled Practical Neuropsychiatry for Clinicians. The second day of the course was all about traumatic brain injuries that included the definitions, clinical syndromes, diagnosis, pathophysiology, and treatment.  Traumatic brain injuries are very common in the US in terms of overall incidence and prevalence (2) and also by comparisons with other neurological and psychiatric diseases.  56,800 people died of TBIs  in 2014 including 2.529 children.  The common injuries leading to death include intentional self-harm (32.5%), falls (28.1%), and motor vehicle accidents (18.7%).   Older patients are at highest risk.  The overall prevalence as a percentage of the population at about 1.5% rivals major mental disorders.

The goal of this post is to describe my traumatic brain injury from long ago using modern criteria to suggest the best possible format to record this information.  First off, was it a concussion or a traumatic brain injury (TBI)?  The CDC definition of TBI is a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head or a penetrating head injury.  The jolt to the head can include blast injuries or any sudden acceleration/deceleration movement to the head.  Disrupted brain function must occur in proximity to the injury and can be observed by changes in level of consciousness, memory loss, focal neurological findings, or additional mental status changes.  Once the mechanism of injury and clinical features have been determined further classification into mild, moderate and severe TBI can be made.

And what is the difference between a TBI and a concussion?  Concussions are by definition with or without loss of consciousness but are described with a number of symptom complexes (headaches, irritability, insomnia, depression, etc) but there are no major neurological symptoms or imaging evidence of injury.  The classification of mild, moderate and severe TBI is done on the basis of the time where consciousness was lost, Glasgow Coma Scale ratings at the time of presentation (see Supplement 1), presence of neurological findings, presence of imaging and EEG abnormalities.  Using these definitions a concussion would be considered a mild TBI according to those categories.

My opening question to people is whether or not they have ever been knocked out. An affirmative response means a concussion or at the minimum mild TBI.  If no LOC questions about associated post-concussion symptoms are relevant.  On a clinical basis, using this scale retrospectively without access to the original record can be a problem, but patients often remember relevant parts of the records.  For example, people often recall if they were told that their imaging study was abnormal or not. They can recall hearing that they had "blood in the brain" and in some cases that they were in a TBI rehab program for a while.  A description of the approximate periods of retrograde and anterograde amnesia is also useful.  For example, in the case of the TBI that I sustained - it would be mild.  I could also say I had a concussion. Both are better specified with comments about the specific features.  Actual loss of consciousness (LOC) was on the order of minutes.  Altered consciousness was about 18 hours.  My guess is that the GCS would have been a 15 if I had been taken to the emergency department and because I was not seen by a physician no imaging studies or EEGs were done.  Subsequent to this injury I have had normal MRI scans and EEGs.  If I was seeing myself as a patient based on that history I might document:

"There is a remote history of a mild TBI that occurred following a collision during a football game with several minutes of LOC, a minute or two of retrograde amnesia, and 18 hours of altered consciousness with patchy anterograde amnesia. There were no postconcussional symptoms past 18 hours. The patient has had subsequent MRI scans of the brain and EEGs  both years later that were noted to be normal."

Other useful descriptions include what the ICD-10 describes as the disparate symptoms of postconcussional syndrome.

In the weeks ahead I hope to post more information on the pathophysiology of traumatic brain injuries and why that is important to psychiatrists.  For now I will just be grateful that the poor judgment of my 22 year old self did not lead to significant disability or death.  There is some epidemiological data to suggest patients with TBIs are more likely to get Alzheimer's disease so I may not be out of the woods yet.  The good news is that this is an active area of research, that treatment approaches do work for people with deficits, but like all of medicine these days they are rationed by health care companies.


George Dawson, MD, DFAPA


References:

1:   Centers for Disease Control and Prevention. (2015). Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Atlanta, GA. Link

2: GBD 2016 Traumatic Brain Injury and Spinal Cord Injury Collaborators. Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019 Jan;18(1):56-87. doi: 10.1016/S1474-4422(18)30415-0. Epub 2018 Nov 26. PubMed PMID: 30497965. Link

3:  Brain Injury Awareness Month — March 2019. MMWR Morb Mortal Wkly Rep 2019;68:237. DOI: http://dx.doi.org/10.15585/mmwr.mm6810a1

4:  Bellner J, Jensen S-M, Lexell J, Romner B. Diagnostic criteria and the use of ICD-10 codes to define and classify minor head injury. Journal of Neurology, Neurosurgery and Psychiatry 2003;74:351-2. Link

5: Defense and Veterans Brain Injury Center.  ICD-10 Coding Guidance for Traumatic Brain Injury. Link

Additional Resource:

Neuropsychiatry Pocket Reference or Brain Card by Sheldon Benjamin, MD and Margo Lauterbach, MD is a booklet of 7 laminated reference cards that covers the neuropsychiatric exam and syndromes of interest to psychiatrists working in this field. It is an excellent inexpensive resource that connects the purchaser to a web site of extensive additional information. Available from braineducators.com

Supplementary 1:

Why Finger-Pointing and Self Flagellation Don't Work

This post is an effort to address some of the rhetoric that is focused on psychiatrists by other psychiatrists. It can be traced back to some of the replies posted here on this blog. But the real impetus today is a thread on Twitter. Twitter is an interesting format for studying dynamics during discussions. It has significant limitations but some of the highlights are interesting. The thread of interest started out as an exchange between myself and another clinical psychiatrist on the issue of the intensive treatment of patients with psychotic disorders specifically early intervention. My responses noted below.

In my experience two groups are overlooked that result in chronicity:
-post partum psychosis
-bipolar disorder with psychosis

Have seen both groups poorly stabilized and rediagnosed as schizoaffective and then schizophrenia.

Both need very intense effort at first diagnosis.

— George Dawson (@dawso007) July 26, 2019

What followed was a fairly rapid deterioration in this exchange. There were the usual comments about how diagnoses are really “labels” and wouldn’t it be nice if we had a different name for the label. From there things progressed to talk about stigma and how it was a significant problem that we need to address. There was also the question about the “dark past” of psychiatry and how there needs to be some kind of atonement for that. I made the basic point that I don’t come from a dark past of psychiatry and there are more positive ways to proceed. From there, one of the posters who was a psychiatrist put up references to what he meant about a “dark past”.  His references were both highly problematic. For example, in the first reference he discusses drapetomania as one of the dark chapters in psychiatry without realizing that the term has nothing to do with psychiatrists. The term is straight out of the anti-psychiatry playbook.  In a second reference (1) there is a chapter from the Schizophrenia Bulletin on the political abuses of psychiatry. There are no references to the political abuses psychiatry in the United States. I might be concerned if I was practicing psychiatry in Russia or China.  It seems that if more countries had the patient safety and civil rights safeguards in place like the United States has - the political abuse of psychiatry would be far less likely.  The arguments about atoning for the “dark past” on the basis of the provided references appear to not apply to my statement about not needing to atone for anything.

As a person who understands rhetoric and who knows psychiatry, there are plenty of historical problems that can be characterized as problematic. That is true of any medical specialty. What is difficult to understand is why a person who is practicing psychiatry is criticizing the field using anti-psychiatry rhetoric. I criticize the drapetomania reference in this post that was written by a psychiatrist defining the field of critical psychiatry (par 10).  I will attempt to summarize the arguments and illustrate my approach.

1. Everyone is biased including psychiatrists- 

My position has always been that psychiatrists receive more extensive training in recognizing and eliminating bias than anyone. That is not a popular position to take in today’s political climate where the fastest way to win an argument is to suggest than someone has an unconscious bias that only you can recognize. The overwhelming evidence that what I am saying is true is basically the training of current and previous generations of psychiatrists. Psychiatrists learn how to talk to people from all backgrounds and cultures. They learn how to communicate with people who have difficulty communicating with other doctors or even their family members. They are trained in aspects of the interpersonal relationship that allow them to analyze that relationship both diagnostically and from a therapeutic standpoint. Beyond that it should be very clear that this communication process happens every day and multiple times a day. Psychiatrists are consulted for difficult analyze problems and they make medical diagnoses - in addition to psychiatric diagnoses - based on these communication techniques.  This is the the work of psychiatry and everybody I know in the field is there because they know it and they are interested in it.

2. Psychiatrists are biased against patients with particular diagnoses-

 One of the concerns that came up was that there are certain diagnoses specifically personality disorders that psychiatrists would prefer not to treat. In clinical practice no matter what your specialty, one of the professional goals is to find a certain niche. I preferred to treat patients who were very ill and many of them had significant personality disorders. There are different approaches to personality disorders and treatment can occur without using that diagnosis as long as there is a specific problem list. The other factor is the number of resources necessary to provide treatment. It is common these days for people to be referred for dialectical behavior therapy (DBT) whether they have the requisite diagnosis or not. That explanation will not suffice for people who believe that personality disorder diagnoses are inappropriate labels that should be eliminated and that they have a problem that has no specific treatment. The reality is that current treatments work and that is what psychiatrists are focused on.

I have had other physicians tell me that they wanted to go into psychiatry, but they experienced intense emotional reactions when talking with people who had certain diagnoses. That could be a specific personality disorder diagnosis or extreme affects associated with other conditions. It highlights the fact that psychiatrists want to be able to communicate with people that others avoid and they are successful at doing so.

3. Psychiatrists should listen to people who are critical or in some cases abusive because there needs to be an “atonement” with the past-

I got a reaction from some people because of my matter-of-fact statement that there is nothing for me to atone for. Interestingly, most of the psychiatrists holding this opinion are all from the United Kingdom. Irrelevant rhetoric aside, additional analysis might be useful. The first has to do with the way the criticism is presented. In a public forum it is common for people to attack psychiatrists and suggest that they are “arrogant” because they refuse to listen to a long list of complaints. At one point, a reference was made to problematic treatment in some institution. The poster referred to the fact that a patient had died from a bowel obstruction and alluded to gross mistreatment. The problem with that type of argument is - were psychiatrists involved? What were the specifics? Where are the authorities?

Whenever people have anonymously complained about psychiatrists and mistreatment I typically ask them why they have not filed a complaint with regulatory authorities. At least I used to do that until I realized they really don’t want an answer or solution. They just want to make psychiatrists look bad. I realize that I was dealing with a lot of people from the UK, but let me discuss how things go in the United States. There are federal and state regulations on the practice of medicine. The ultimate authority and whether a physician is disciplined up to and including loss of license is the state medical board. In the state where I practice, any complaint is thoroughly investigated. That means the complaint does not have to be accurate or even coherent. If any complaint is filed against a physician, the medical board contacts them and requests all of the relevant records and a response from that physician within two weeks. A failure to respond results in disciplinary measures that may include loss of license and the ability to practice medicine. There are independent entities that report on how many physicians are disciplined in every state and encourages people to file complaints. They have rating systems that suggest whether or not enough complaints are filed against physicians. That is a very low threshold for dealing with complaints about physicians.

All physicians must apply for a new medical license every year. On that medical license physicians must attest to the fact that they do not have any substance use problems, medical problems that impair their ability to practice, and have not committed any crimes. They also have to attest that they are not under investigation by any hospital, clinic, professional organization or the board of medical practice. All controlled substance prescriptions are tracked by physician and patient. In the state where I work there is also an Ombudsman who is located in the Governor’s office and is charged with investigating complaints against the vulnerable adults. Vulnerable adults by definition include people with mental disorders, addictions, and developmental disabilities. An Ombudsman investigation is totally independent from the medical board.

I can’t say what happens in the UK, but patient safety is a priority in the US rather than the reputation of any doctor. With all the safeguards in place,  I don’t know why anyone would post information on social media about being injured or abused by any physician without going through this process.

Since most physicians in the US are employees, that is another area of oversight. Practically all medical organizations solicit physician ratings from patients being seen and aggregate those ratings around each physician. They are used to “incentivize” physicians to get more optimal ratings. They are also used to intimidate physicians into doing what their administrators want them to do. Any significant complaint from a patient or a fellow healthcare professional would result in a physician needing to meet with an administrator.  That internal employer investigation must be reported to the medical board and credentialing agencies.

In the extreme, malpractice litigation is another source of oversight but there is an admittedly a mixed agenda. Malpractice litigation occurs both in the United States and the UK, suggesting to me that with some of the extreme scenarios described in social media this litigation would be an obvious approach.

These levels of physician oversight, suggests that the complaints leveled against psychiatrists in social media have either not been brought to the responsible authorities or they don’t exist. These processes also suggest that there is no room for a “dark” present at least not without discipline or loss of license. Physicians have a fiduciary responsibility to their patients and very clear accountability. Specific responsibility is a much clearer way to approach the problem than suggesting that everyone atone for some vague injustices.

 4. There are no unique psychiatrists and you don't have to be unique to do good work –

 The final bit of rhetoric that I encountered was in the form of a hashtag #NotAllPsychiatrists. The discussant in this case was another psychiatrist from the UK who suggested that using that hashtag as an argument to counter the blanket condemnation of psychiatrists “gets us nowhere”. He was suggesting that psychiatrists should listen to all possible complaints and that by using this hashtag “it suggests we are interested in listening”.  Unless you believe that most or all psychiatrists harm patients this is an argument based on a false premise.  The hashtag itself is as rhetorical as well as the statement that all complaints should be listened to by all psychiatrists.  Each psychiatrist listens to  the patient sitting directly in front of them. They have responsibility to that person.  The psychiatrists I know are preoccupied with not making mistakes and they generally do a good job of that.   A more appropriate hashtag to counter the blanket condemnations might be #PracticallyNoPsychiatrists.

This idea is not productive in other ways.  Direct observation of my colleagues suggests that we are all uniformly trained and the idea that one psychiatrist is “better” than another is a convenient illusion subject to context. I have seen more than one mistake made when a psychiatrist was blamed for something beyond their control and their colleagues were not supportive. That seems to be the dynamic operating here when discussions among colleagues suddenly become forums for complaints against psychiatrists. It is also a convenient way to just win an argument. In other words, there is no good reason for a psychiatrist to not want to listen to complaints about the profession in a conversation that started as a professional discussion about psychiatry. Case closed!

This is some of the rhetoric used against psychiatrists in social media and unfortunately much of the finger-pointing and self-flagellation is from psychiatrists themselves. I pointed out clear reasons why it is unnecessary. There are currently plenty of more functional avenues for complaints against physicians and they should be utilized.

And no psychiatrist out there should be suggesting that they have a superior position when it comes to caring for patients or endorsing blanket criticism of the field.



George Dawson, MD, DFAPA


References:

1:   van Voren R. Political abuse of psychiatry--an historical overview. Schizophr Bull. 2010 Jan;36(1):33-5. doi: 10.1093/schbul/sbp119. Epub 2009 Nov 5. PubMed PMID: 19892821
.

Supplementary:

One of the qualifiers for this post is that psychiatric practice is being compared between the US and the UK.  Reading literature written by psychiatrists from the UK for decades I can't imagine the practice there is much different.


Graphic Credit:

The "words have power" graphic is from Shutterstock per their standard user agreement.  The artist is gerasimov_foto_174.  I thought it was very appropo for this post because many of the intense critics and in many cases maligners of psychiatry have power as their predominate focus. Most psychiatrists don't see the world that way and in fact realize that in most cases we are lucky to be able to secure the most appropriate treatment for our patients.

Do Anti -Torture Arguments Apply To Some Utilization Review Decisions?

In a previous post on psychiatry and torture, I pointed out the American Psychiatric Association's official position paper on torture.  It states unequivocally that psychiatrists should not be involved in  torture and describes the premises for that argument.  As any reader of this blog knows, I have described the impact of managed care on psychiatry including the fact that managed care has had a disproportionate effect on the field probably because of widespread biases against psychiatry, psychiatrists, and patients with psychiatric disorders and addictions.  Some would cite the subjective nature of the field, but the abuses I have seen occur in areas where  there is limited subjectivity such as inpatient and treatment settings where there are unequivocal and severe disorders.  Obvious examples would be people with psychotic disorders who are engaged in unsafe activities due to delusions and/or hallucinations or a person compulsively drinking 1.75 liters of vodka per day despite having numerous auto accidents and nearly freezing to death because of intoxication.  Every psychiatrist I know is aware of cases where these people have been denied care by an insurance company based on an arbitrary decision made by a remote reviewer who has no responsibility to the patient in question.  Although many of these patients are oblivious to their plight and would be content to proceed with no treatment, many are highly distressed.  They are distressed because they know that proceeding with no treatment places them at risk on several fronts and the basic act of being denied coverage causes them a great deal of distress.

That lead me to the thought: "Is this distress the equivalent of torture?"  As always that depends on the definition.  Post 911, the United States has used various definitions of torture including some that rationalize actual physical blows to a person as not constituting torture.  Timelines of various Department of Justice memos with these interpretations are available and I will not get into them here.   There are obvious problems with not calling a coercive beating torture.  A more widely accepted definition is available from the United Nations:

1:  For the purposes of this Convention, torture means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions.

In this case, torture is defined as potentially mental suffering with no physical component.  Since the UN is dealing with torture inflicted by states there is the expected implication of states in the process and the cases of lawful imposition of pain and suffering inflicted by states.  The definition is also limited to obtaining information that a person wants to keep undisclosed or coercing them to do something they do not want to do.  A more general dictionary definition from Webster's would be:

To afflict with severe pain of body or mind.

Part of the convenience to businesses denying psychiatric care is the stereotype that these are just minor medical conditions, that treatment is elective, or that treatment does not meet some arbitrary business criteria like "failing outpatient treatment first" or "we don't do medical detox in a hospital".  The pain involved with mental illness is an abstract concept to anyone who has not experienced it or who has not be involved in trying to treat it.  I don't think it has been studied.  You won't see anyone asking the question:

How painful was it to learn that your insurance company would not fund for the treatment of your mental illness or substance abuse problem and realize that you would be losing your home, spouse, children, job, etc?

Professionals treating the patients in question also avoid the issue of psychic pain.  It can be more easily dealt with as the expected anxiety or depression of an adjustment disorder rather than unnecessary suffering inflicted by a third party.  Some professionals will address it as grief from the expected losses.  But most often it is just glossed over as business as usual. The legal system has already indemnified managed care systems from any liability for decisions that lead to injury removing them further from the consciousness of patients, their families and the providers in question.  The physicians involved are conflicted - they know they are powerless given the legal landscape and further they don't want to make any waves with the companies who might be paying them.  We have culturally removed one of the most toxic factors in our health care system - the denial of care from consideration.

Like all psychiatrists, I have had to pick up the pieces when the proposed treatment plan is denied and all of the secondary problems come into play.  Suddenly I am talking with a person who not only has a severe psychiatric problem and/or addiction, but they are now homeless or without a job or a family.  It is the worst care scenario from the perspective of comprehensive care and it is up to me and my colleagues to piece together a suboptimal plan.   The outcomes of those suboptimal plans are rarely very good.  The best that I usually hope for is that they can be safe for a long enough period of time to find other resources to deal with their chronic mental illness or addiction.  In some cases the expected worst case scenario occurs and if the patient is lucky they are readmitted and there is another chance to try to obtain funding from their managed care company.  There is a good chance the proposed plan will be refused again.

At what point is the human suffering involved in this sequence of events recognized?  At what point does a change in the system need to occur.  Steven Sharfstein, MD made this decision when he was the President of the APA and he banned the participation of psychiatrists in any step of the interrogations occurring in the mid 1990s to this date.  Is that a step that psychiatry should consider in managed care settings?  Should we eliminate psychiatrists from sitting in a remote office and reading notes about the care of one of these severely ill patients and making a decision that favors the insurance company that they work for?  Psychiatric professional societies have adapted to the cultural blindness of the culpability of insurance companies when they legitimize medical decisions by making sure that some psychiatrists are in these reviewer positions.  I guess  the thinking was that they could suspend their loyalty to their employer to make decisions in the best interests of patients and the profession.  History has clearly showed that things don't work that way.  I have had some reviewers tell me that their decisions were based on a set number of days irrespective of anything I would tell them about illness severity or complications.

I can understand the obvious counterargument to my position that the denial of care is a form of torture.  It can be argued that the patient is not a passive player and that they have a "choice" about whether they continue to have severe symptoms, continue to use drugs and alcohol, or continue to harm themselves.  The idea that all of these problems are based on conscious voluntary choices remains an unrealistic business approach to mental illnesses and addictions and not reality.  There is also the business as usual argument.  That is - this is the way we have done things for the past 30 years with the help of politicians even though it does not contain costs and it provides poor quality care.  It that really enough justification for creating more stress on already distressed patients?

At what point do we all acknowledge that denied psychiatric care results in more mental pain and suffering and takes psychiatrists out of decisions that are in their patients best interest?


George Dawson, MD, DFAPA




Graphics Credit:

Graphic is downloaded from Shutterstock per their standard agreement.  It is entitled "Depressed man in a tunnel" by the artist hikron.

Epistemic Injustice Is Misapplied to Psychiatry

Some of the greatest minds in psychiatry have emphasized the importance of philosophy in the field and done some excellent work in that area. Unfortunately philosophy can also be used to attack the field and when it is, some of that work is not very well done. Since I’ve been writing this blog there have been a couple of examples. The first was the argument that the DSM-5 was a “blueprint for living”. My counterargument is available at this link and you can read the subsequent dialogue. It should be evident from my argument that the DSM-5 is the farthest thing from the blueprint for living that a psychiatrist could imagine. The political context for that article in the New York Times was the supposed controversy about the DSM-5. It was being portrayed in the media as almost apocalyptic and this opinion piece fit right in.  I always viewed the DSM-5 as the non-event that it proved to be.

The second couple of articles focused on critical psychiatry. One was an opinion piece about critical psychiatry and the second was a summary of critical psychiatry written by a couple of critical psychiatrists. In the philosophy literature as it applies to psychiatry there is always a lot of hedging around the issue of whether philosophical critics are anti-psychiatrists or something else. Some authors for example refer to them as skeptics. I have no problem with the school that sees them as anti-psychiatrists and made the argument that if critical psychiatrists based their criticism on antipsychiatry philosophers they are in fact anti-psychiatrists.

The latest philosophical criticism of psychiatry is an opinion piece (1) called “Epistemic injustice in psychiatry.” It is written by an author who has a doctorate in philosophy and is a psychiatrist and two academic philosophers. Their main thesis is that epistemic injustice occurs to a number of people based on biases against them and this prejudice undermines their credibility in that context.  In the case of medical treatment, that means the patient is not taken seriously and their treatment plan would be more unilateral on the part of the provider rather than collaborative and seriously considering their input. But I don’t want to minimize the authors definition and so I am including it at this point below:

“Epistemic injustice is harm done to a person in her capacity as an epistemic subject (a knower, a reasoner, a questioner) by undermining her capacity to engage in epistemic practices such as giving knowledge to others (testifying) or making sense of one’s experience (interpreting). It typically arises when a hearer does not take the statements of the speaker as seriously as they deserve to be taken.”

They cite racism and sexism as good examples where prejudical stereotypes lead to the subjects information being discounted. They build on this idea and suggest that people with mental illness are subjected to similar biases. From there they extrapolate and say that physicians and psychiatrists in particular make these same biased assessments and discount what patients say to them. They acknowledge that there are some circumstances where the credibility the patient may be questioned. They also suggest that this epistemic injustice is more likely to happen with psychiatric patients than other patients with physical illnesses. They suggest this has a detrimental effect on psychiatric patients, funding psychiatric services, and public perception.

They describe three examples of “epistemic injustice in psychiatry”. In all three cases the patients were put on acute psychiatric holds. In the first case a man claimed to be related to a Soviet leader and that was seen as delusional when it was true. In the second case a woman had cultural beliefs and practices that were misinterpreted as delusions. In the third case the patient had chronic suicidal thinking and visited the same cliff numerous times. He was admitted on hold when he was at the cliff for an hour and the decision was eventually made to treat him as a chronic high-risk patient on a voluntary basis. In all three cases the patients were released from the hospital by the civil commitment authority.

There are several problems with these vignettes and the inferences. The first is that the patients are being held on legal basis and not because of a psychiatric diagnosis. At least that is what happens in the United States. In other words, people cannot be held on the basis of a diagnosis they also have to present an imminent danger to themselves or others. It is a contested legal process and that in itself blurs the diagnosis and inhibits communication. The vignettes also seem to say that people are never adequately assessed based on their history and released even before the legal hold is released. As an acute care psychiatrist I have had to assess and release thousands of people when we determined that the history they gave us was accurate. In other words we believed them and released them. Of all the people I assessed and treated I am not aware of anyone who was released by a court because I made in an inaccurate assessment by not listening to the patient.

The authors move on to talk about contributory factors for epistemic injustice.  They discuss a number of archaic stereotypes (for a psychiatrist) of people with mental illness such as believing substance use users have a “lack of willpower” and that they are responsible for their own particular problems. I have never really met a psychiatrist with these beliefs and doubt that people with those beliefs go into psychiatry. I have certainly met other medical specialists with these beliefs and in fact argue with them regularly about that. The authors do have a rare point when they point out that negative stereotypes and stigma lead voters and politicians to underfund treatment for mental illness but that has nothing to do with the way psychiatrists communicate with their patients.

They discuss the topic of hard versus soft evidence. They use this to develop the argument that health professionals have epistemic power because “only they have access to this evidence and have the training to interpret it”. They really stretch to come up with the statement that some psychiatrists think of their patients as "objects of epistemic inquiry" rather than collaborators. I wonder if the authors are familiar with the psychiatric concept of therapeutic alliance. In the therapeutic alliance the psychiatrist and the patient are active collaborators and both the psychiatrist and the patient focus on solving problems that the patient identifies. That is an active process that as far as I know is taught to all psychiatrists. It wouldn’t work if a psychiatrist was looking at the patient as an object of inquiry.

The third contributor to epistemic injustice is negative stereotypes. The common stereotype mentioned by the authors is that “people with a mental illness are responsible for their condition”. I don’t think any psychiatrists think this way but at the end of this section the authors go back to making an argument about how psychiatric services are inadequately funded because the public and politicians maintain these negative stereotypes. So in the end two of the three contributory factors have more to do with the public’s lack of knowledge about psychiatric disorders than how psychiatrists function.

They discuss dementia and schizophrenia as conditions where the patient’s input may be minimized because of cognitive factors or their psychiatric status. The main stereotypes mentioned are the dangerousness stereotype with schizophrenia and the hopeless case stereotype with dementia. It is very difficult to understand how either of these descriptions support their main argument. Psychiatrists are trained to weigh what the patient is telling them and whether or not it might be plausible. Compared to practically all people - psychiatrists should have the best framework for what might or might not be plausible in the area of human behavior.  I can recall being interrupted during team meetings with news that one of my patients had communicated some behavior that the staff in the room were discounting as implausible and I suppose that is congruent with the authors’ argument. Those behaviors range from self reports of severe self endangering behavior to behaviors with a high likelihood of aggression. In most cases I considered the patient report to be accurate.  I had no doubt that a very low frequency behavior had occurred based on that patient’s history and in those cases it was generally corroborated.

The authors do not elaborate on the case where the patient's statements are uncritically accepted by the treating physician.  That is a likely cause of overprescribing and unnecessary testing.   

The entire first section of the paper does not seem to reflect modern psychiatric practice. I just put up a post on about 50 different factors that can be discussed with the patient at the end of the interview and a few real life examples of what is discussed. All treatment planning is based on what the patient says in that interview. The authors examples are cases where psychiatry and psychiatric assessment is secondary to legal considerations and all the impaired communication that involves. So there appears to be no epistemic injustice at the level of psychiatrist talking to patients in an outpatient setting.  The only exception would be a psychiatrist with insufficient expertise or one under severe constraints.  Those constraints can include a lack of time with the patient and unrealistic productivity and paperwork demands by the bureaucracy. 

The authors move on to discuss ways to overcome epistemic injustice. They suggest changing training to emphasize the subjective perspective of patients. I don’t understand that argument because the psychiatric evaluation should be focused entirely on the subjective perspective of patients. If the psychiatrist has any technical expertise at all, empathy is used to communicate that the psychiatrist knows what the patient is going through. The best description of empathy comes from British psychiatry as follows:

“Empathy is achieved by precise, insightful, persistent and knowledgeable questioning until the doctor is able to give an account of the patient’s subjective experience that the patient recognizes as his own.” (2)

That hardly seems like an exercise in disbelieving or ignoring what the patient has to say. Further psychiatric assessment should be focused on the entire conscious state of the patient rather than just what they have to say. Psychiatrists should be adept at diagnosing and treating patients who are unconscious and comatose, delirious, cognitively impaired, and experiencing severe psychiatric symptoms. A psychiatric assessment is more than believing what is said. I have frequently been in the position of having to explain to the patient what was happening to them and helping them make sense of their current experience. That is a singular focus on the patient’s subjective state when they are confused and unable to describe it.

The authors suggest multidisciplinary teams with a focus on the emotional aspects of care. I don’t know if that happens in England but in the United States I had team meetings every day for 22 years. The emotional aspect of care including interpersonal dynamics with patients and among the staff was routinely discussed in those meetings.

The authors suggest that medical students should be “taught to believe what psychiatric patients tell them unless there is a good reason not to do so”. My hope would be that medical students are able to see how attending physicians approach evaluations and treat psychiatric patients much differently than other physicians. The main factors that lead to that different approach include therapeutic neutrality, a lack of bias toward people with severe psychiatric disorders and addictions, and an ability to talk to all people with those problems. There is a more technical point that might not be as evident and that is psychiatrists are the only physicians who are systematically trained to understand and analyze their reactions to the patient and what that might mean. That is what psychiatrists do and why they are consulted by other physicians and by everyone else when problems are significant.

A much better approach is to go after institutional countertransference or the collective emotional and interpersonal reactions that can be seen institution wide based on psychiatric and addiction diagnoses. This is the single most important factor in being able to provide quality care to people with these conditions. A negative institutional countertransference toward these patients is evident in most hospitals and clinics where I have worked.  Only one person - the director of an emergency medicine program was interested in addressing it and had me speak as a consultant at a Grand Rounds on the subject. These negative attitudes are driven to an extent by stereotypes but also by the neglectful way society and political systems treat these people. They have been cast as a burden on the medical system, always uncooperative, people who deserve minimal if any treatment, and their treatment resources are cut to the bone. Psychiatrists working in these settings and promoting a model of therapeutic neutrality facilitating appropriate care is one of the best solutions - but more cooperation outside of the psychiatric community is needed.

In summary, epistemic injustice appears to be another philosophical concept that is misapplied to psychiatry.   There is no doubt that people can be misdiagnosed. There is no doubt that things don’t always go well. There is a clear reason for that and that is everyone coming to see a psychiatrist has a unique conscious state. There is no catalog of every unique conscious state. The psychiatrist's job is to understand that unique conscious state and it happens through direct communication with that person.  That direct communication can happen only if the psychiatrist is an unbiased listener.

George Dawson, MD, DFAPA

References:


1: Crichton P, Carel H, Kidd IJ. Epistemic injustice in psychiatry. BJPsych Bull.  2017 Apr;41(2):65-70. doi: 10.1192/pb.bp.115.050682. PubMed PMID: 28400962;

2: Sims A. Symptoms in the Mind. Elsevier Limited; London; 2003; p 3.


Graphic Credit:

The above photo was downloaded from Shutterstock per their standard user agreement.  The title is
Joshua Trees in Mojave Desert, California by Dean Stanisavljevic.