Recent Opinion About Diagnostic Heterogeneity – Gets It Wrong

There was an opinion piece about categorical diagnosis in psychiatry and diagnostic heterogeneity that was published in Psychiatric Research weeks ago (1), that generated a lot of controversy.  The controversy started when an online publication characterized the article as showing that Psychiatric Diagnoses Found to Be "Scientifically Meaningless".  The author of that article subsequently posted that the article was written by science undergraduates re-purposed as science writers.  If this was supposed to be investigative journalism it failed at several levels not the least of which is the apparent conflict of interest by the authors. Instead the internet article basically quotes the authors as factual and scientific rather than a rhetorical opinion piece.  What follows is my take on the Psychiatric Research Article.

The first sign of bias that a reader may encounter in the original article is right in the abstract. The concluding sentence reads:

“A pragmatic approach to psychiatric assessment, allowing for recognition of individual experience, may therefore be a more effective way of understanding distress than maintaining commitment to a disingenuous categorical system.” (my emphasis added).

When I read this sentence, it was difficult for me to believe that peer reviewers for a psychiatric journal could allow it to pass. In one sentence the authors are allowed to distort and discredit psychiatric clinical methods and diagnostic methods that have been carefully developed for over a century.  I won’t belabor the definition of “disingenuous” but it is safe to say that the expenditures in terms of brainpower and money as well as the transparency of the process make the production of the DSM 5 one of the more rigorous approaches to a diagnostic system in medicine. The people sitting on the DSM 5 committees for each section were acknowledged experts in their fields with decades of experience and published research.  Production of the DSM-5 was also a multiyear process that took 14 years to develop prior to its publication in 2015 (2).  During that time there was a multiyear grant that sponsored 13 international conferences on specific diagnostic issues.  Guiding principles and conceptual issues were examined.  Public input was solicited. Hundreds of clinicians and researchers were involved.  There was transparency about potential conflicts of interest. It was not just an intense effort – it was a unique diagnostic effort in terms of overall vigor and resource utilization.   Describing the output of all of this work as “disingenuous” and getting that in print lead me to question the peer review and editorial process.  Are the editors and reviewers ignorant of the effort that went into the diagnostic categories or don’t they care? It is clear that the authors of this article don’t.

The second red flag in the paper to anyone familiar with typical antipsychiatry arguments is the mention of Foucault and the suggestion that psychiatric classification occurs within wider sociocultural developments and that these roots have resulted in diagnostic heterogeneity.  In fact, Foucault’s observations of psychiatry were inaccurate at the time and have not held up at all over the course of time. The authors seem to ignore the actual reasons for categorical diagnosis in the first place and list none of those references.  Practically all modern DSM work can be traced back to the reference generally referred to as the Feighner criteria (3).  Reading those papers, clearly describes categorical diagnosis as a work in progress and the importance of diagnosis. The authors also describe five phases for the validation of psychiatric diagnoses.  They have this comment on diagnostic heterogeneity:

“In the absence of known etiology or pathogenesis, which is true of the more common psychiatric disorders, marked differences in outcome, such as between complete recovery and chronic illness, suggests that the group is not homogeneous. This latter point is not as compelling in suggesting diagnostic heterogeneity as is the finding of a change in diagnosis. The same illness may have variable prognosis, but until we know more about the fundamental nature of common psychiatric illnesses, marked differences in outcome should be regarded as a challenge to the validity of the original diagnosis.” p 57.

These authors suggested 5 phases to establish the diagnostic validity of psychiatric illness including the clinical description, laboratory studies, delimitation from other disorders, follow-up studies, and family studies.  There are entire texts dedicated to some of these markers on epidemiology and family studies.  One of the mandates of the DSM-5 committees was to review all of this data and compile it into the most clinically useful form.  In the interim they happened to pare the total number of diagnoses from a maximum of 297 in DSM-IV to 157 in DSM-5 (see reference 2, p xxiii).  This is the basis of categorical diagnosis – not the narrative of a philosopher.

Contrary to the idea that the current authors and the like-minded authors they have referenced have discovered diagnostic heterogeneity it has been widely acknowledged from the outset and by all current psychiatrists. There are no surprises here especially for people trained as physicians. Practically every complex biological illness is heterogeneous with heterogeneous outcomes as well as polygenic etiologies.  Their Foucauldian criticism also ignores the fact that the Washington University group was based on empirical research as opposed to the psychoanalytic process of the day.
 

The example of the empirical approach is illustrated by tracing the development of Major Depression criteria from 1950 to 1980. In fact, many in that group were highly skeptical of psychoanalysis as a possible diagnostic process at all. As they started to publish research article, one of their original articles was highly edited by a psychoanalyst/editor to remove any reference to the term diagnosis. 

The second acknowledged aspect of psychiatric diagnosis and treatment that is given short shrift by the authors is the issue the value of both diagnosis and formulation or as Kendler, et al discuss:

“However, neither we nor, we think, the developers of the criteria would claim that assessing operationalized diagnostic criteria is all there is to a good psychiatric evaluation. While critical, a diagnosis does not reflect everything we want to know about a patient. Our diagnostic criteria, however detailed, never contain all the important features of psychiatric illness that we should care about.” (see reference 4 p. 141.)

The authors’ research method is an exercise in subjectivity.  They basically read five chapters in the DSM 5 (schizophrenia spectrum and other psychotic disorders, anxiety disorders, bipolar and related disorders, trauma and stressor related disorders, and anxiety disorders) and use a technique called “thematic analysis” “to code themes or patterns of meaning across diagnostic categories being analyzed, with a particular focus on the heterogeneity or differences across types of diagnostic criteria.”  You don’t need an advanced research seminar to figure out what is wrong with that picture. Here is a group of psychologists several of whom make a career out of criticizing psychiatry and who are building a case that psychiatric diagnoses are inferior to their own vague diagnostic system using a qualitative technique that even their reference (5) refers to as having “no particular kudos as an analytic method – this, we argue, stems from the very fact that it is poorly demarcated and claimed, yet widely used”.  What outcome would any objective observer expect?

The combinatorics argument:

The authors make it seem like large combinations of diagnostic features mean categorical diagnoses are problematic.  Although they don’t say it explicitly - referring to more diagnoses greater than the number of stars in the solar system - suggests improbability.  But do large combinations of number preclude reasonable human use?  A chess board for example has an 8 x 8 square configuration and by some estimates - 10¹³⁷ moves are possible.  And yet players at all levels seem to be able to negotiate a chess board and determine win, lose or draw.  Master players can develop strategies that make them more likely to win.  Is there similar evidence that diagnoses with large combinations can be managed the same way?  What follows is a mixed table of a psychiatric diagnosis (PTSD) that yields a large number of combinations of diagnostic criteria on the left, a dimensional scale for depression (DEP) from a standard psychological test (MMPI), two different criteria for systemic lupus erythematosus (SLE), and criteria for asthma. Qualifiers for each column are listed at the bottom.

Disorder	PTSD (1)	MMPI-DEP (2)	SLE (ACR) (3)	SLE (SLICC) (4)	Asthma (5)
Criteria	Presence of 1 (or more) of the following symptoms: 1. 2. 3. 4. 5. One or both of the following symptoms: 1. 2. Two (or more) of the following: 1. 2. 3. 4. 5. 6. 7. Two (or more) of the following: 1. 2. 3. 4. 5. 6.	15/26 items	4 of 11 criteria: 1. 2. 3. 4. 5. 6. 7.   A or B 8.   A or B 9.   A or B 10. A or B or C or D 11. A or B or C or D or E	4 of 17 criteria including at least 1 clinical criterion and 1 immunologic criterion; or biopsy proven lupus nephritis: 1.   A or B 2.   A or B 3.   4.   A or B 5.   A or B 6.   A or B 7.   A or B 8.   A or B 9.   10. A or B 11. 12. 13. 14. 15. 16. A or B 17.	1. A or B or C or D 2. A1 or A2 or A3  or B or C
Minimal Combinations	3,150	7.726160e6	330	2,380	36
Total Possible Combinations	636,120	7.726160e6 + 5.311735e6 + 3.124550e6 + 1.562275e6 + 657800 + 230230 + 65780 + 14950 + 2600 + 325	12,555	321,489	46

Footnotes:

1.  This column is from the reference: Galatzer-Levy, I.R., Bryant, R.A., 2013. 636,120 Ways to have posttraumatic stress disorder. Perspect. Psychol. Sci. 8, 651–662.

2.  I have several opinions from different psychologists on the current use of this MMPI scale and the raw cut-off scores. I understand that there are different raw scores for men and women. I can recalculate this scale based on any numbers that may be deemed more reliable. Just email them to me along with the evidence.

3.  American College of Rheumatology (ACR) classification criteria for Systemic Lupus Erythematosus

4.  Systemic Lupus International Collaborating Clinics (SLICC) proposed revised classification criteria for Systemic Lupus Erythematosus

5.  There are numerous endophenotyping classifications for asthma.  It is clear at this point there is no comprehensive system of clinical classification.

What can be observed from this table?   

Apart from waxing poetically they seem to not recognize that common psychological approaches scale to an even larger extent – much greater than 10¹⁸. I have also demonstrated that the way diagnostic criteria are worded makes a big difference in counting word combinations.  Just using the DSM phrasing “or more” greatly increases the number of combinations.  Criteria designed like the SLE criteria as a series of “A or B” choices that greatly reduce the number of possible combinations.  On the other hand dimensional criteria like a single scale from a popular psychological test – greatly increases the number of possible combinations because that scale is a many n and many k.  Using a 15/26 item scale results in 10⁷ combinations.  Using that as a ball park estimate for the other clinical scales results in numbers far larger than used by the authors to criticize categorical diagnosis.  The other aspect of this table is that less combinations is not necessarily better. With asthma for example, these numbers are based on very basic diagnostic criteria.  There are at least 2 other 6 item endophenotype systems and an additional cough variant asthma, but currently experts in the field have not developed a way to incorporate that level of clinical complexity into diagnostic criteria that would be useful to clinicians. Low number of combinations of diagnoses criteria are not necessarily better than higher numbers – especially when the disease complexity is not captured.  

The second issue with combinatorics is that they are not predictive of anything. Great strides in treating post-traumatic stress disorder have occurred in the past 30 years using criteria with a high number of combinations.  That obviously does not preclude patient selection or monitoring in clinical trials of either psychotherapy or pharmacotherapy. It does not prevent the successful diagnosis and treatment of patients in clinical settings in many cases where severe and potentially fatal psychiatric illness exists.  As an example, delirious mania had a fatality rate of 75% in 1849 in the United States (7). That number has fallen to zero with psychiatric treatment based on categorial diagnosis and the clinical training of psychiatrists to recognize severe illness. Many of those improvements have occurred in the past 30-50 years. 

  

In the authors selection strategy, large sections of the DSM 5 that clearly disprove the author’s contentions are omitted. The elimination of Neurocognitive Disorders, Sleep-Wake Disorders, and Substance Related and Addictive Disorders for example also eliminates biological markers and autopsy validation of criteria of diagnoses.  Table 1 (p. 482 of DSM-5) contains 127 discrete categorical diagnoses across 10 categories of substances. 

But the larger misunderstanding here is that what the authors disparage as heterogeneity is an expected part of medicine. Every physician knows that no two patients with asthma, benign prostatic hypertrophy, or gout are the same. There are a collection of illness features with some overlap but no truly homogeneous categories – even in clinical trials that attempt to minimize it. Biological systems especially the brain are designed to scale in various ways including based on combinatorics of various biological elements.  The author’s use of the term quadrillion, happens to be the estimated number of synapses in the brain but that is just a starting point of how systems in the human brain can scale.  The endothelial system in the human body has more cells than the brain and massive heterogeneity that allows for regulation of the vascular beds the human body. The hematopoietic and immune systems have similar levels of scaling that could also result in very large number of combinations. In none of these cases do the number of combinations of cell types, connections, tissue behavior, or descriptions preclude diagnoses, research or treatment.  A very small sample of this heterogeneity is suggested by the table below.  

Heterogeneity In Normal Functioning And Disease States In Human Biology (very partial list)

Endothelial cells	Diabetic nephropathy
Hematopoietic Stem Cells	Hepatitis C virus
Neuroendocrine Neoplasms	Ischemic Stroke
Leukemia - Clonal and Intraclonal cell types	Prostate Cancer
Aphasia syndromes	Mitochondrial Myopathies
Atrial Fibrillation Syndromes	Asthma
Immunodeficiency syndromes	Coriticobasal Degeneration
Diabetes Mellitus Type I and II	Viral Syndromes
Congestive Heart Failure	Cryptospridium genus and species

The authors ignore clinical heterogeneity that physicians have to address in their patients every day.  Very few physicians see clinical trials subjects as patients requesting assistance. That means comorbid physical illnesses, variations in patient tolerance of medical and psychological interventions, pharmacokinetic and pharmacodynamic factors, heart disease, liver disease, renal disease, substance use disorders, traumatic brain injuries, old age, pediatric age, suicide risk, aggression risk, impaired functional capacity, and even pregnancy have to be addressed in patients being seen every day by psychiatrists and adjustments have to be made. Only physicians schooled in heterogeneity would be able to treat those people.  Only physicians schooled in heterogeneity would realize that the people in clinical trials are rarely the people being seen in the office.  

In conclusion, the authors have a poor understanding of diagnostic heterogeneity and why it is a central part of medicine.  Some of their arguments are similar to arguments offered up by the critics of Kraepelin in the early 20^th century.  Other arguments - like the combinatorial ones reflect a poor understanding of biological systems and how they scale as well as a lack of understanding of medicine. Physicians know for example that diagnostic models are not completely explanatory, that over time - the explanations change, but that science exists at some level of that explanation or treatment. That is the nature of biological as opposed to physical systems. Anyone interested in these issues can find a rich literature out there that describes these problems and even the involved philosophy. Unfortunately, only one of the authors referenced (out of 28) is written by anyone authoritative in that area.

The only disappointment greater than an article like this being published is the fact that it was published in the journal Psychiatric Research.  It has little to do with psychiatry or research and it is shocking that the obvious problems with article were overlooked. On the other hand, this journal was never at the top of my reading list and this may be why.

George Dawson, MD, DFAPA

References:

1: Allsopp K, Read J, Corcoran R, Kinderman P. Heterogeneity in psychiatric diagnostic classification. Psychiatry Res. 2019 Sep;279:15-22. doi: 10.1016/j.psychres.2019.07.005. Epub 2019 Jul 2. PubMed PMID: 31279246.

2:  Black DW, Grant JE.  DSM-5 Guidebook. American Psychiatric Publishing, Arlington, VA: pp 543.

3: Feighner JP, Robins E, Guze SB, Woodruff RA Jr, Winokur G, Munoz R. Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry. 1972 Jan;26(1):57-63. PubMed PMID: 5009428.

4: Kendler KS, Muñoz RA, Murphy G. The development of the Feighner criteria: a historical perspective. Am J Psychiatry. 2010 Feb;167(2):134-42. doi: 10.1176/appi.ajp.2009.09081155. Epub 2009 Dec 15. PubMed PMID: 20008944.

5: Braun, V., Clarke, V., 2006. Using thematic analysis in psychology. Qual. Res. Psychol. 3, 77–101. https://doi.org/10.1191/1478088706qp063oa.

6: Kendler KS, Engstrom EJ. Criticisms of Kraepelin's Psychiatric Nosology: 1896-1927. Am J Psychiatry. 2018 Apr 1;175(4):316-326. doi: 10.1176/appi.ajp.2017.17070730. Epub 2017 Dec 15. PubMed PMID: 29241358.

7: Bell, L., 1849. On a form of disease resembling some advanced stage of mania and fever. Am. J. Insanity 6, 97–127. 

Happy Labor Day 2019

I decided to keep posting a Labor Day greeting to my fellow physicians. I’ve been doing this since 2013 and previously linked to all of those pages. Now there is a search feature in the upper right corner of this blog and you can just search on Labor Day if you are interested. My post this year is truncated based on the fact that very little has changed since my fairly comprehensive post 2018. If you will look up that post I comment on physician productivity, the EHR, pharmaceutical benefit managers, managed care and health insurance companies, maintenance of certification, and burnout in some detail. The advances in these areas have been too trivial to comment on in terms of either progress or the chronic lack of progress. I am sure that some organizations would like to debate that. The APA for example would point out that a health insurance company was successfully sued for failing to reimburse care for mental illness. The judge in that case actually made some fairly critical remarks directed at the managed care company, but on a day-to-day basis the average psychiatrist and the patients they are treating notice nothing but continued oppression.

Psychiatrists and their patients traditionally have fewer resources than other physicians and standard medical and surgical care. The overwhelming signs of this include jails being used as psychiatric holding tanks (I refuse to consider them hospitals) and the ongoing bed shortage. That bed shortage leads to overcrowding in emergency departments and a tendency for patients with mental illness to be the only ones discharged untreated from emergency departments. That often happens after they’ve been held there without treatment for days at a time.

There is something basically wrong with a government and political system that refuses to provide humane and equitable care for people with mental illnesses on the one hand and blames them for societal problems on the other. Just earlier today in the context of yet another mass shooting I heard the President describe the perpetrator as being “very mentally ill”. This occurred after a recent visit to the White House by a National Rifle Association representative. During that visit the president was talked out of advocating for universal background checks and the party line became “blame the mentally ill for mass shootings”.  It appears that the executive branch has a red line that they won’t cross when it comes to rational gun policy and a second red line that they won’t cross when it comes to providing equitable treatment for people with mental illness and addictions.

I think that is a relevant Labor Day observation for physicians because these irrational policies affect all of us. As psychiatrists we see very mentally ill people go in and out of hospitals and administrators pressure us to get them out before they are stable.  They are typically discharged to minimal outpatient services. We experience the tension of trying to get people off of inpatient medical and surgical units or out of the emergency department to appropriate psychiatric settings when there are none. Our physician colleagues feel that pressure. We all recognize that we were not taught to treat people this way in medical school. The only reason we do is that physicians no longer control the practice of medicine. Business administrators and people with no medical qualifications do control the practice of medicine. I repost the graphic here that was sent to me by David Himmelstein, MD who also gave me permission to use it on this blog.  Just getting rid of all of that bad management would result in saving a trillion dollars and bringing US health care costs in line with the country with the second highest per capita costs - Switzerland. 

It is clear to me that the problem with the physician work environment - the place we all labor intensely for too many hours - is a problem with administrators. Never before in the history of medicine have we had so many administrators telling us what to do. The graphic clearly illustrates that.  As working physicians we all know what that means.  We know it means when an administrator suddenly has a “great” idea that is not based on science or medicine and we all have to live with it for months or years. We all know what it means when a group of administrators suggests that we are not getting patients out of the hospital fast enough even when they are still ill.  We know what it means when we have a lengthy meeting with administrators for our “input” only to learn that they didn’t really want our input they just wanted to tell us how things were going to be for the rest of our career. And if you are as old as me, you might recall a time when medical departments were run by physicians and they had business managers who took care of business. In those days there were clear boundaries between medicine and business - not like it is today.  We are well past that point now.  The practice environment is a boundaryless morass of business people telling physicians, pharmacists, and patients what to do.  The rationale for this morass (cost containment) is no longer visible - probably becuase this model has failed miserably. Instead there are massive costs and a massive transfer of those direct costs to patients and indirect costs to physicians.

It has also resulted in the lowest possible quality of care.  The quality of medical care and how that is measured became a secondary consideration when businesses took over medicine.  A clear example is the treatment of depression on an outpatient basis. One of the standards promoted by the managed care industry is measurement based care using a scale like the PHQ-9 for ongoing assessment.  Unfortunately this process lends itself to using the measurement as a diagnosis and rapid route to treatment with antidepressants. Several approaches to depression including subsyndromal depression in primary care settings are ignored and PHQ-9 scores are followed as a measure of quality improvement.  This is the type of gross oversimplification that occurs when clinical medicine (1) is ignored in the context of businesses claiming that their measurement process is superior.

These inefficiencies in the day-to-day work of physicians are presented as improvements that we should all be happy to go along with.  In many cases administrative catch phrases like: "Change is good" accompany the poorly thought out and unscientifically implemented policies. The practice environment for physicians will only improve if the  bean counters no longer run medicine.

Until then Labor Day will be just that.

George Dawson, MD, DFAPA




Reference:

1: Arroll B, Chin WY, Moir F, Dowrick C. An evidence-based first consultation for depression: nine key messages. Br J Gen Pract. 2018 Apr;68(669):200-201. doi: 10.3399/bjgp18X695681. PubMed PMID: 29592945

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
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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.