What do you hate about it?

[splik]

Psychiatry is usually hated by most because of the shaky science. A Psychiatrist is supposed to learn mental health on a medical and biological level.

No a psychiatrist leans about mental illness, not mental health. The emphasis is on biomedical discourses, but we should also learn cognitive, behavioral, psychodynamic, systemic, social realist, social constructivist, and possibly existential models of mental illness too - though the emphasis is usually on biomedical and psychodynamic with a bit of the cognitive-behavioral thrown in.

And i don't think DSM-5 is going to do that. I do think that we have to put more focus on biology and start researching ways to make more illness clean cut (psychosis and manic depression are examples of clean cut ton me, ADHD and Autism still need more research IMO.)

You can't make arbitrary constructions clean-cut - there is nothing clear cut about manic depression and psychosis, not in diagnosis, not in phenomenology, not in genetics, not in epidemiology because 'schizophrenia' and 'bipolar disorder' are essentially arbitrary constructs from trying to categorize and classify forms of madness that have no external validity in reality, and then trying to validate them by finding genetics, neural substrates and so on and acting surprised when you don't come up with anything! One of my professors was the leading schizophrenia researcher in the world at the time, and told us there was nothing clear cut about distinguishing schizophrenia from bipolar, or even teasing apart psychotic symptoms in the general population, from those who were mentally ill. I'm biased of course, but I think we need to put more emphasis onto epidemiology, phenomenology and studying psychiatric symptoms in the healthy population to understand why some people develop some mental disorders, and others don't, or why one person develops 'schizophrenia' and another bipolar disorder. Without a pretty good description (and I don't think the RDC or DSM-X did give decent criteria for research) and a good understanding of the occurrence of various symptoms in the populations we have no chance of doing proper work with genetics or imaging etc. The other problem with genetics is we have typically stopped with associations - most studies these days are case-control studies - they look for SNPs using GWAS or copy number variations, or chromosomal microdeletions. They rarely (if ever) look at biological plausibility - i.e. what does this gene or SNP do that provides a plausible explanation for this association?

Time and time again you will see a pt diagnosed with bipolar who comes in psychotic with no affective symptoms and you will think - how can this person have been dx with bipolar, they look schizophrenic! I have even had attending say "this patient doesn't have a bipolar bone in their body!" and then you chat to some other psychiatrist or nursing staff and they will say "I remember this guy, he was floridly manic the last time he was here.." - so they end up either being dx with schizophrenia or schizo-affective disorder, which is essentially a relic of our neo-kraepelinian dichotomy.

Psychiatry is one of the few specialties where we don't rely on special investigations and instead on the history and physical. This is where the money is in pretty much every specialty. 85% of the diagnosis in neurology is in the history (symptoms, temporality, risk factors and so on), about 10% in the examination - but today we rely heavily in imaging and other investigations. These should mostly be used to confirm the diagnosis. Could you imagine if I told a patient "Your blood test and fMRI and MEG scans confirm the diagnosis of depression." - They would say "I could have told you that!" The art of psychiatry and its humanity is wedded to our emphasis on the history and interviewing. I can't help but feel something is being eroded in quest for biomarkers. I think it would be great if you could have a way of knowing with high sensitivity/specificity whether a depressed pt is bipolar or unipolar, but can't help but feel that what would happen is what has happened in the rest of medicine - investigations will become used to make the diagnosis, at the expense of an empathic, considered, and thorough assessment, instead of to support the diagnosis, which is how they should be used.

---

Members don't see this ad.

 

[DOC PENGUIN]

No a psychiatrist leans about mental illness, not mental health. The emphasis is on biomedical discourses, but we should also learn cognitive, behavioral, psychodynamic, systemic, social realist, social constructivist, and possibly existential models of mental illness too - though the emphasis is usually on biomedical and psychodynamic with a bit of the cognitive-behavioral thrown in.



You can't make arbitrary constructions clean-cut - there is nothing clear cut about manic depression and psychosis, not in diagnosis, not in phenomenology, not in genetics, not in epidemiology because 'schizophrenia' and 'bipolar disorder' are essentially arbitrary constructs from trying to categorize and classify forms of madness that have no external validity in reality, and then trying to validate them by finding genetics, neural substrates and so on and acting surprised when you don't come up with anything! One of my professors was the leading schizophrenia researcher in the world at the time, and told us there was nothing clear cut about distinguishing schizophrenia from bipolar, or even teasing apart psychotic symptoms in the general population, from those who were mentally ill. I'm biased of course, but I think we need to put more emphasis onto epidemiology, phenomenology and studying psychiatric symptoms in the healthy population to understand why some people develop some mental disorders, and others don't, or why one person develops 'schizophrenia' and another bipolar disorder. Without a pretty good description (and I don't think the RDC or DSM-X did give decent criteria for research) and a good understanding of the occurrence of various symptoms in the populations we have no chance of doing proper work with genetics or imaging etc. The other problem with genetics is we have typically stopped with associations - most studies these days are case-control studies - they look for SNPs using GWAS or copy number variations, or chromosomal microdeletions. They rarely (if ever) look at biological plausibility - i.e. what does this gene or SNP do that provides a plausible explanation for this association?

Time and time again you will see a pt diagnosed with bipolar who comes in psychotic with no affective symptoms and you will think - how can this person have been dx with bipolar, they look schizophrenic! I have even had attending say "this patient doesn't have a bipolar bone in their body!" and then you chat to some other psychiatrist or nursing staff and they will say "I remember this guy, he was floridly manic the last time he was here.." - so they end up either being dx with schizophrenia or schizo-affective disorder, which is essentially a relic of our neo-kraepelinian dichotomy.

Psychiatry is one of the few specialties where we don't rely on special investigations and instead on the history and physical. This is where the money is in pretty much every specialty. 85% of the diagnosis in neurology is in the history (symptoms, temporality, risk factors and so on), about 10% in the examination - but today we rely heavily in imaging and other investigations. These should mostly be used to confirm the diagnosis. Could you imagine if I told a patient "Your blood test and fMRI and MEG scans confirm the diagnosis of depression." - They would say "I could have told you that!" The art of psychiatry and its humanity is wedded to our emphasis on the history and interviewing. I can't help but feel something is being eroded in quest for biomarkers. I think it would be great if you could have a way of knowing with high sensitivity/specificity whether a depressed pt is bipolar or unipolar, but can't help but feel that what would happen is what has happened in the rest of medicine - investigations will become used to make the diagnosis, at the expense of an empathic, considered, and thorough assessment, instead of to support the diagnosis, which is how they should be used.

I agree with you that we need to put more emphasis on epidemiology, phenomenology and studying psychiatric symptoms in the healthy population. My stupid point was the shaky science that psychiatry faces. The reason most people hate the psychiatry field is that we have made great progression, it is just not the progression that others want. Why is it that Neurology gets to brag about how they are the last frontier of medicine when they still don't know much about parkinson's. why is it that we get scrutinized because of our use of pharmaceuticals. We have the biggest image problem among doctors and patients and i want to change that. (I know i can't though)

I am sorry if i offended you as a resident, my point was that the science is still shaky and the connotation that psychs are the bottom rung or that psychiatry is a fake will persist, since we find people spouting how little biological evidence there is for certain illness. In fact, the UK government is training psychologists because of Psychiatric use of SSRI's. i believe the studies in britain have shown how political the field can be. And the bolded part shows my favorite part so your post.

 

[splik]

In fact, the UK government is training psychologists because of Psychiatric use of SSRI's. i believe the studies in britain have shown how political the field can be. And the bolded part shows my favorite part so your post.

This is not quite correct. The reason the UK expanded training for psychological therapies through the IAPT (increasing access to psychological therapies) program was two-fold. Firstly, the NICE (National Institute for Clinical Excellence) recommended that CBT should be first-line for mild to moderate depression (after guided self-help etc). But CBT was not widely available for this to be the case, so SSRIs were still used as first line inappropriately. The second reason was the Economist Lord Layard claimed that depression was a scourge on the economy through absenteeism and lost productivity, and that CBT was an effective treatment and that training 10 000 more CBT therapists would pay for itself because of the economic burden of depression. This is a specious claim, because there is no evidence supporting CBT increasing return to work (the opposite appears to be true, it doesn't reduce absenteeism or work-based stress/depression), and secondly the studies were done at academic supercenters not in the community where most therapists work, and even in RCTs at least 1/3 patients never turn up to their first session, and the attrition rate for CBT is actually quite high. Not to mention the complex reasons that prevent access to therapy and act as barriers to engagement in the first place.

You can read more about Layard's initial proposal here: The case for psychological treatment centres and you can read a critique here and a debate here
http://www.rcpsych.ac.uk/training/studentassociates/newsletters/newsletterfebruary2010.aspx#7

 

[vistaril]

We have the biggest image problem among doctors and patients and i want to change that. (I know i can't though)

I am sorry if i offended you as a resident, my point was that the science is still shaky and the connotation that psychs are the bottom rung or that psychiatry is a fake will persist, .

what?! you mean psychiatrists aren't seen as equal colleagues to surgeons and oncologists?! I'm shocked

our image problem is mostly based on the following:

1) the shaky science for a medical model. Psychiatry has less ebm for it than any other field....by far. in neuro, for example, even where there is limited therapy for a certain condition, this is often somewhat balanced by the very well elucidated mechanism of that illness. neurologists may not be able to do a whole hell of a lot for a massive ischemic stroke a day later affecting some region of the brain, but the way they can precisely trace out the mechanism of the injury itself and the precise effects of it based on neuroanatomy is impressive.
2) the perception that psychiatrists just tinker around with meds(partly true, partly not)
3) the quality of people on average going into psychiatry.

I don't neccessarily see any of those three getting any better.

 

[toothless rufus]

I don't understand the whole prestige thing when considering the realities of day-to-day practice. Do what you love (or at least like) or you will be miserable no matter what perceived opinion is. And no amount of money makes hell any more palatable.(unless you can make enough to retire on in a few grueling unhappy years in a specialty you don't enjoy)

 

[diagonal]

I don't understand the whole prestige thing when considering the realities of day-to-day practice. Do what you love (or at least like) or you will be miserable no matter what perceived opinion is. And no amount of money makes hell any more palatable.(unless you can make enough to retire on in a few grueling unhappy years in a specialty you don't enjoy)

Truer words never spoken.

And let's not even get into the reality of prestige. Do people really think anyone gives a **** about you and your prestige? Wait for it................the answer is a resounding NO. It's ego to the highest degree, and it's funny for some to be so smart, yet so stupid, and fail to realize that no one gives a damn. The most prestigious doctor in the world, when introducing himself (the most prestigious doctor in the world isn't a woman) gets a blip - a second or two - of admiration in the mind of the onlooker, which is then quickly replaced by the pre-existing mental drama and self-centeredness and judgment that pervades all our internal worlds.

No one gives a **** bro. Live a life that inspires YOU.

 

[aphenomenon]

No a psychiatrist leans about mental illness, not mental health. The emphasis is on biomedical discourses, but we should also learn cognitive, behavioral, psychodynamic, systemic, social realist, social constructivist, and possibly existential models of mental illness too - though the emphasis is usually on biomedical and psychodynamic with a bit of the cognitive-behavioral thrown in.



You can't make arbitrary constructions clean-cut - there is nothing clear cut about manic depression and psychosis, not in diagnosis, not in phenomenology, not in genetics, not in epidemiology because 'schizophrenia' and 'bipolar disorder' are essentially arbitrary constructs from trying to categorize and classify forms of madness that have no external validity in reality, and then trying to validate them by finding genetics, neural substrates and so on and acting surprised when you don't come up with anything! One of my professors was the leading schizophrenia researcher in the world at the time, and told us there was nothing clear cut about distinguishing schizophrenia from bipolar, or even teasing apart psychotic symptoms in the general population, from those who were mentally ill. I'm biased of course, but I think we need to put more emphasis onto epidemiology, phenomenology and studying psychiatric symptoms in the healthy population to understand why some people develop some mental disorders, and others don't, or why one person develops 'schizophrenia' and another bipolar disorder. Without a pretty good description (and I don't think the RDC or DSM-X did give decent criteria for research) and a good understanding of the occurrence of various symptoms in the populations we have no chance of doing proper work with genetics or imaging etc. The other problem with genetics is we have typically stopped with associations - most studies these days are case-control studies - they look for SNPs using GWAS or copy number variations, or chromosomal microdeletions. They rarely (if ever) look at biological plausibility - i.e. what does this gene or SNP do that provides a plausible explanation for this association?

Time and time again you will see a pt diagnosed with bipolar who comes in psychotic with no affective symptoms and you will think - how can this person have been dx with bipolar, they look schizophrenic! I have even had attending say "this patient doesn't have a bipolar bone in their body!" and then you chat to some other psychiatrist or nursing staff and they will say "I remember this guy, he was floridly manic the last time he was here.." - so they end up either being dx with schizophrenia or schizo-affective disorder, which is essentially a relic of our neo-kraepelinian dichotomy.

Psychiatry is one of the few specialties where we don't rely on special investigations and instead on the history and physical. This is where the money is in pretty much every specialty. 85% of the diagnosis in neurology is in the history (symptoms, temporality, risk factors and so on), about 10% in the examination - but today we rely heavily in imaging and other investigations. These should mostly be used to confirm the diagnosis. Could you imagine if I told a patient "Your blood test and fMRI and MEG scans confirm the diagnosis of depression." - They would say "I could have told you that!" The art of psychiatry and its humanity is wedded to our emphasis on the history and interviewing. I can't help but feel something is being eroded in quest for biomarkers. I think it would be great if you could have a way of knowing with high sensitivity/specificity whether a depressed pt is bipolar or unipolar, but can't help but feel that what would happen is what has happened in the rest of medicine - investigations will become used to make the diagnosis, at the expense of an empathic, considered, and thorough assessment, instead of to support the diagnosis, which is how they should be used.

Thank you.

 

[DOC PENGUIN]

what?! you mean psychiatrists aren't seen as equal colleagues to surgeons and oncologists?! I'm shocked - i never meant that but it is partly true to stuck up patients.

our image problem is mostly based on the following:

1) the shaky science for a medical model. Psychiatry has less ebm ?for it than any other field....by far. in neuro, for example, even where there is limited therapy for a certain condition, this is often somewhat balanced by the very well elucidated mechanism of that illness. neurologists may not be able to do a whole hell of a lot for a massive ischemic stroke a day later affecting some region of the brain, but the way they can precisely trace out the mechanism of the injury itself and the precise effects of it based on neuroanatomy is impressive.- Still, We all know that psychiatry is tinkering with centuries of human development from philosophies to psychology. We are basically dealing with the highest function of MAN. How do we map it and when can we start? I think it is impossible.
2) the perception that psychiatrists just tinker around with meds(partly true, partly not)- Thats why Pharm.D's help and a klot of other specialties also prescribe psychiatric medication.
3) the quality of people on average going into psychiatry.- how can we change it.

I don't neccessarily see any of those three getting any better.

I hope you like the annotations. I am sorry for being an *******.