Diagnosis Can Be Simpler

… But Some Might Say “Oversimplified”

Treatment of behavioral health patients begins with an initial interview. The significance of a reasonably accurate diagnosis is paramount to providing quality care. Many have noticed the increased thickness of the DSM-5 diagnostic reference. Every new edition holds the promise of increased number of distinct diagnoses. At last count, one source estimates the total number of distinct diagnoses at 600, not counting the specifiers which would increase the number to tens of thousands.

It is my opinion that they can only reasonably expect that practitioners can distinguish between 6 major categories for adults. Regarding children and adolescents, there may be three additional categories. If you can place the patient in one of these categories effectively and accurately, you are already more competent than most professionals that I’ve encountered in my time a psychiatrist. Keep it simple and leave room for improvement of the patient. Diagnosis is a fluid practice, and should not be treated as a sentence.

Adults

Psychosis and mood disorders

Psychosis and mood disorders are rooted in structural and biochemical abnormalities.

At some future time, I will describe the disparity between why I think major depression is diagnosed. When cyclothymic disorder would fit many folks, the psychiatrist tends to diagnose more severely than necessary. While medication treatment may be similar, the physician or psychiatrist will tend towards a diagnosis which reduces resistance from managed care and insurance companies.

Personality Disorders

Initially originate in the toddler stage which is 15 to 24 months. Originates 15 to 24 months typically as a result of separation anxiety.

There seem to be four distinct personality disorders. Currently, the official diagnostic list has increased to ten. I do not see the usefulness of breaking out this disorder so granularly especially as it relates to treatment.

Organic Brain Syndrome

Multiple adverse environmental and or structural elements are related to OBS. It can be caused by events such as trauma or aging and is related to structural biochemical difficulties in the brain. Acute OBS is observed as delusions (poor reality testing) secondary to a reversible condition, an example being sleep deprivation. Chronic OBS secondary to permanent changes in the brain’s functioning. In both, reality testing is poor (delusions), inability to abstract. In chronic OBS the individual has learned how to confabulate conversations in reasonable simple social interactions. Confabulate is defined as “to fill in the gaps in memory by fabrications”.

Children

Autistic Spectrum, ADD/ADHD

Not being a child psychiatrist, I can only list those diagnoses as found primarily in children. If any of you are aware of different diagnoses that could be considered, feel free to share your view.

Now that we have some idea of diagnosis and the biochemical set up, we can try to the put the two together to come up with treatment.

There are 4 schools of treatment:

• Biochemical treatment: this is most popular in modern psychiatry
• Talk therapy: this include psychoanalysis which is most orthodoxically belongs to Freud and his method
  This includes psychodynamic which is part included in talk therapy but is usually done only once a week and is most commonly done one-on-one (one therapist, one patient)
• Behavioral therapy: this is more popular with some psychologists.
• Social theories: the smallest school of treatment by far. This is the one to which I am most attuned.

I have little or no experience with behavioral therapy, so you will not read much from me about stimulus in/response out. Although there is much to be said for that, I only think of that being seen in a social context, so that the family, peers, and emotional culture in which a person lives has a predominant effect on our “emotional self” before it affects our “behavioral self”

The most debilitating psychiatric illnesses relate to disorders of biochemistry and/or structure in our brains. The first objective of the psychiatrist is determined if the basis of the difficulty is an organic brain syndrome or a biochemical/structural disorder. In the first part of the interview the therapist asks open ended questions and listens to the organization of the patient’s response.

With schizophrenia or manic depressive disorder, the patient has difficulty organizing their answer. The anxiety from an open-ended question will induce what is known as loose associations from people with schizophrenia. Speech patterns of loose associations show a person jumping from one topic to another without regard for the relevance. The topics are typically only loosely associated (hence the name). Similarly, the patient will fail to return to the original topic.

A manic person has the symptom of flight of ideas which represents rapid talking with jumping associations from one loosely related topic to another. The difference between the two is that the manic person does not lose contact with the initial topic at hand, and can display the ability to return.

In depressive psychosis, individuals see no “light in the tunnel” so to speak. If there is a light, it is coming from behind them. They display a paucity of ideas, with the exception at the end of their life. This can usually be noticed immediately in the facial and body expressions and slow response time. Without medications, derailments and flight of ideas can be improved with close-ended questions. At rock concerts, this approach was used to calm patrons who had taken LSD or other hallucinogens. Stimulus from the outside (light, noise, conversation) will speed up the process for these symptoms, which can be seen in manic depressive disorder if one is paying close attention. With schizophrenia, outside stimuli increases internal anxiety, and is an important issue.

Not so much used as a diagnostic tool as a treatment tool. For example, in the hospital, a patient is seen as providing an increasingly manic episode. It would beneficial to isolate and cut out external stimuli. Whereas a schizophrenic is more bothered by voices, etc. it would be best to help by having a calming external stimulus to cut down on psychotic reverberations.

In psychiatry, there are folks who use anecdotal evidence that very wealthy people will express the fear that they won’t have any clothes to wear a month or a year down the road.

For treatment, there are three major transmitters either too high or too low. With schizophrenia, it tends to be dopamine, which is too high. With manic depressive it is serotonin and norepinephrine, both of which vary to present varying symptoms. Some severe anxiety spectrum disorders treatment is helped a great deal by medications (OCD, PTSD, agoraphobia).

With both manic depressive and schizophrenic psychotic episodes blocking postsynaptic dopamine receptors is helpful. With manic episodes, it is also helpful to calm down the presynaptic nerve membranes. This can be done with lithium and/or specific anti-seizure medications, particularly depakote trileptal and possibly keppra.

Decreasing external stimuli is helpful in the short run with manic episodes, however this should be tempered with social interactions to counteract the patient’s unrealistic expectations of themselves and to learn to trust other folks and their environment.

Depressive Psychosis

Major depression is pharmacologically treated by increasing the amounts of serotonin and norepinephrine in the presynaptic nerve terminals. This is done initially by blocking the uptake mechanism with SNRIs, SSRIs. These block the uptake mechanism and look like they would increase the number of transmitter molecules in the synaptic cleft. This is temporary and thus cannot be the total mechanism of action/treatment. For a long time, there was a question of why it would take ten days to two weeks for the antidepressant effect to take hold. It’s been my guess that it is a two or three step process. The immediate 24 to 36 hours the number of molecules in the synaptic cleft are increased but in the vesicles they are decreased. There is a feedback mechanism to the body of the presynaptic neuron to increase the synthesis of the transmitter and in this is transported down to the vesicles at the nerve ending. Once the manufacturing has increased sufficiently to regain a balance, then the depressive symptomatology is gone. This would help explain two anomalies:

1. the ten days to two weeks wait time for the antidepressant to work
2. the increase in suicidal thoughts from the second to the tenth day

ECT electroconvulsive treatments are more effective than pharmacological or biochemical treatment. The exact mechanism is not well studied because you cannot take brain biopsies in humans. However, in rats, the amounts of neurotransmitters vary in parallel to what is seen in antidepressant medications. Experience in humans show that it is 95% effective in humans where antidepressant medications are only 70% effective. In addition, actively suicidal patients will become confused and not able to carry out any suicidal gestures if given ECT three or four days in a row.

Cocaine blocks the transport receptors but does not make good long term antidepressants. Amphetamines also increase the activity of neurotransmitter in the synaptic cleft, but that mechanism action is to stimulate the release of the transmitter by replacing them in the vesicles, so with long enough use, it causes a relative depletion of the transmitter on their own accord. Cocaine was initially popularized by Freud in his Cocaine Papers — he was particularly impressed by the Andean people’s ability work in high altitude, required less food, increased productivity while chewing the cocoa. Freud was an evangelist of cocaine — even introducing it to his friend, his wife, and his mother. He explored the topical anesthetic properties of cocaine. His work led to the first eye surgery by two ophthalmologists whom had heard about cocaine from Freud. In my own practice, I recall two or three hospital patients where antidepressants were not showing any effect. Two of them, upon telling them that I intended to treat them with ETC, replied “if I’m alive Monday then you can start”. Both of them did very well with a series of six to eight ETC treatments.

PTSD is a good example in that it the main difficulty may be the inability to visualize the traumatic episode because any time the patient talks about the event, fight/flight mechanism takes over. This requires the patient to physically remove himself from whatever he is doing at the moment, which stops the mind from processing and observing the memory in a constructive way.

Anxiety

Starting with personality disorders which I find are best thought of as issues that come up from separation in ages 1 to 2 years of age, just as the child is learning to walk reasonably well. At times, the child will walk away from “Mother Figure” sufficiently losing contact and thus security with the MF. This loss is devastating to both parties. In psych speak, they have been “abandoned” by their good mother and “pushed off the cliff” by the bad mother. Upon seeing the MF again, the child feels rescued, but angry and hostile towards MF for being abandoned. This leads to the reentering of what the Neo-Freudians call the rapprochement phase. In this phase, if all is well, the feelings of security return and the child is encouraged to explore his independence. This happens hundreds of times, then thousands of times throughout the toddling phase. If the majority of times, reproachment is positive, then the toddler will have a positive, secure attachment to his mother. If for whatever reason it does not go well, many toddlers will have ongoing feelings of abandonment, most likely towards the bad mother. Although there are four or five common personality disorder diagnoses, all of them have this in common.

As these folks grow up, they will continue to deal with adversity as if they are an 18 month old and try to deal with feelings of abandonment and hostility in the same way over and over. The particular type of personality disorder is like reading the different sides of a square, with the hostility and anger and feelings of despair. All of this has a common figure being a different faces of the same square. Borderline, narcissistic, paranoid, inadequacy, skeezoid. The best known of these are borderline and narcissistic personality disorder, which are treated with a combination of talk and pharmacologically.

The term borderline came from Otto Kernberg who originally called it borderline personality structure. Under extreme stress, the patients can throw tantrums that resemble 24 hour psychosis. It seems to be best treated by talk therapy and very low dose antipsychotic medications.

Anxiety spectrum disorders

Neurotics and hystericals and OCD — all of these fall under the anxiety spectrum. These can best be looked from Freudian triadic relationship paradigm — the mother, the father, and neurotic. It has to do with the Oedipal complex and most resembles three to five year old stage in development. The issue is to resolve the fear of father and love of mother (for males; the Electra complex in women is mythologically based on Electra and Agamemnon’s return from Troy in Arrestis trilogy which is the desire to kill the same sex parents and followed by the furies and is from the infant standpoint dealt with by the age of five. That stage is followed by the latent period where anger goes underground and socializing with peers is dominating — oral/anal phallic is revisited in the slightly different form.

There are anxiety spectrum disorders from social anxiety to PTSD and OCD. These disorders are often helped with psychotropic medications, and in my opinion are best helped with a combination of medication and group therapy. It is, in my opinion, more popular among therapists is cognitive behavioral therapy — it is what you could say an enamored view of its ability to treat anxiety.

CBT

Although cognitive behavioral therapy is quite useful, it is not my preferred approach when I am working with patients. The first method of CBT was rational-emotive therapy. The originator and champion of rational-emotive therapy was Albert Ellis who presented himself in his seminars as a crotchety old man. Behind this facade, one could see that he was particularly caring and attentive. Presently, the popular therapy was developed by Aaron Beck. It was, in my perception, based on the self-talk of the ego being rational (superego) to help quiet the anxiety from childlike desires (id). Thirty or more years ago, transactional analysis was popular. I see many similarities in CBT in that we have a parent, adult and child in our social interactions with one another. In this schema parent is superego, ego is adult, and child is id, which as you know, are Freudian terms. The therapist in these schemes does what is called “ego lending” in psychoanalytic terms. This means that the therapist not only tries to improve the person’s own ego so that he can function better on his own, but the therapist also lends the patient his own ego by helping them rationalize in the talk therapy.

In anxiety, the individual is aware that of their distress because there are physiological symptoms — it resembles a fight or flight reflex. These are, according to evolution, the defense mechanisms of primitive man which had the existential threat of tigers, other tribes, war, etc. In the fight or flight reflex is initiated in the emotional part of the brain which is also associated with the amygdala. The transmitters (adrenaline, noradrenaline) It is sent through the midbrain to the spinal cord, where nicotine is the most common neurotransmitter, and goes to the sympathetic nerve system then to the heart where it beats stronger and faster, then to the lungs where they expand to take in air more efficiently, then to the vessels which generally constrict them (this causes blood flow to go to the muscles). At the same time the parasympathetic nerves goes from the cord to the GI tract and take blood away from the GI tract and push it to the muscles so that the individual is most capable of maximum physical activity.

As infants, toddlers, and teenagers, we develop mechanisms to help allay the fear of our fight or flight status. This either occurs in the higher parts of the brain — the anti-anxiety medications work through the receptors in the midbrain which slow down the amount and effect of the noradrenaline and adrenaline. Physiologically, one will feel less stress because of this process. The benzodiazepine works through receptor sites so there is a maximum effect no matter how much of the drug that one takes. Alcohol anesthetizes nerve membranes so there is no limit to the nerves that can be anesthetized and with sufficient alcohol people will anesthetize their breathing causing them to stop breathing unconsciously. Alcohol will depress nerve action which is in small amounts helpful but in large amounts or even medium amounts over time can become a major problem.

In my experience the four most difficult anxiety problems are due to too strong a defense against the superego which creates the constant fight or flight state.

• Social Anxiety : This seems to be the least debilitating, until it becomes so strong that it morphs into a more severe anxiety. The benzodiazepines: valium adavez xanax have the potential to cause addiction. However, tranxene and cerex are much less likely to cause addiction. The first three seem to have a euphoria in and of itself, while the latter do not. This will become important when talking about detox from alcohol. Some of the antidepressants are favored and seem to be more helpful with one or more of these diagnoses. Paxil and effexor seem to have a better track record for social anxiety as well as for PTSD. In PTSD, it seems that there is a greater need for larger doses compared to just depression itself.
• OCD (obsessional compulsive idsorder) : In my experience, this has best been treated with low dose chlorimipramine and individual CBT. This is the one instant where I think CBT is quite useful. I have never done a CBT myself — I have always contracted this out to a psychology or social worker for this part of the treatment. In OCD treatment, the mantra is often “it’s not me, it’s the OCD”. There are some recent rumors that there may be one or more genetic marker and possible structure anomalies in OCD. In OCD, it is somewhat universal that the individual has intrusive thoughts — these are thoughts that enter the subconscious or conscious triggered by minute observations of something external which in my opinion constitutes the obsessive component, and some ritualistic reflex response is needed and used to dissipate the unwanted, undesired thoughts that are felt to be horrific and produce shame and disgust in the individual. These intrusive thoughts almost always have a sexual and/or angry component that lead to the shame and disgust which then triggers the compulsive act to dissipate the anger and shame and disgust. This is the compulsive part. I had already described the approach that I used to treat OCD.
• Agoraphobia : Agoraphobia and agrophobia are two names for the same illness. It is unsurprising that individuals who live alone and with agoraphobia have problems grocery shopping and going over tall bridges. It is felt that most people — male or female — go through a traumatic situation, some developing PTSD, others not. When Menninger’s was still in Topeka, Kansas, their explanation was that every person with PTSD had to have some sort of childhood trauma. Retraumatization initiates the PTSD. There is a David Sheehan the head of the University of South Florida Medical School — an expert in PTSD — in his seminars says that it the most diagnosable symptom is the hyperalertness. He favors high dose effexor for treatment. There is a book he wrote called the Anxiety Disease which I always recommended to my patients that had PTSD or agoraphobia. The two, in my view are often related — there is even a diagnosis that incorporates both.
• PTSD : This is often treated with high dose prozac or high dose effexor. Early on it was my experience that MAO inhibitor nardil worked best for PTSD. This can create extremely severe side effects of hypertensive crisis or with serotonin syndrome if mixed with any of the antidepressants or some foods and a number of decongestants so it is seldom used in this country. At one time, it was used a great deal in the United Kingdom. Some experts feel that there are two types of PTSD and that childhood trauma is probably more common in females and wartime trauma more common in males.
  According to some people, PTSD is always accompanied with hyper-vigilance. Some people have described PTSD creates a situation where the individual is constantly afraid that their next step will be into quicksand, which creates the need to constantly avoid the next step. One method of avoiding the danger does not continue to alleviate the fear of the quicksand. The individual’s life becomes more and more constricted. As this continues, people will become symptomatic anytime that they go to the grocery store, cross over a high bridge, and will progress to the point where the patient will not leave their home. There are several approaches to treatment for these symptoms. Many are somewhat useful — I have prefered noradil an MAO inhibitor in combination with group therapy. In this case, a homogeneous group made up of clients with severe anxiety problems will be the best group composition. There are other approaches, other medications, and other therapists find them equally as helpful as my method. Recently, beta blockers have been touted as a medication and the necessary mechanism of the beta blocker i to disconnect the physiological response from the external trigger in order to the patient can describe the thoughts and memories of a traumatic event. Beta blockers such as propranolol have been used recently with some feasible success in current literature. Propranolol will block the increase strength of contraction of the heart as well as the heart rate and rise of blood pressure — the theory is that this will decrease perception of anxiety in the patient enough so that they can continue thinking about and expressing the event itself.
• Milieu therapy originated in England in what is called the Northfield Experiment. There were two experiments with this name — one by Wilfred Bion and John Rickman to try treat World War II who had “battle fatigue” which was PTSD by another name. Bion is well known for his writings about group therapy. This is where milieu therapy was created and is in large part the basis for group therapy as it is done in this country.

As stated above, I believe that these are best treated with a combination of medication and group therapy.

The biochemical or pharmacological view is with medications to help lessen the superego’s grip that inhibits the id, because in anxiety disorders the situation is that the superego is too strong which creates guilt and shame because of the id’s desires and the risk of public exposure of desires. Most helpful is a combination with talk therapy are medications that often dampen the overproduction of fight or flight constant state. Most all of the problems stem from too much superego. The job of the therapist is to reduce this. It

The ideal is to have the adult of one person interacting with the adult of the other person rather than a parent to the other’s child. There are a couple of things that I want to say about this

After transactional analysis was popular for several years, most of the practitioners also started to add Gestalt therapy. It is my opinion that for the therapist too much straight rational therapy is not very exciting or enjoyable. I have a strong opinion that if you do not enjoy the hour itself that you are not doing as well as you should. This has a lot to do with why I’ve avoided CBT and transactional analysis, etc.