Leaving Psychiatry. J. R. Ó’Braonáin. M.D.
And the show goes on.
Child psychiatrist 2 formulates the case thus; the child has developed an anxiety disorder. Anxiety is the kissing cousin of fear. When we are afraid we take flight or fight, i.e. in fight mode we manifest aggression under a range of behavioural and affective modes which includes irritability, if not frank violence. In flight mode we may simply withdraw. Anxiety explains the recent truancy, the inattention, the neuro-vegetative dysfunction and, given the unpleasantness of the anxious child’s inner world, can lead to thoughts of suicide. Anxiety isn’t fun and can lead to feeling depressed under the weight of fear. In any case, all roads lead to Rome. Another script of antidepressant is written, for as luck would have it, so called antidepressants are also anxiolytics. Or so they say. This psychiatrist might also refer to a psychologist skilled in the childrens version of CBT, depending on age and maturity.
Psychiatrist number 3 will diagnoses little Jaxxson with ADHD, attention deficit hyperactivity disorder (which is actually an umbrella term which should read attention deficit and/or hyperactivity disorder). How will our psychiatrist manage to accomplish this diagnosis? Actually it’s a simple affair, for if you read the literature of academic and clinical fans of the diagnoses, ADHD can be had in those who are high achievers or low, in those who are dreamy absent minded introverts or rambunctious spinning toys of boys tearing around the classroom like a whirlwind. With a pinch of imagination and an ounce of inclination (the latter of which I lack), I could easily formulate about half of my child and adult patients with ADHD, including of course most drug addicts. With Jaxxson, we could say his recent lack of attentiveness and drop in academic achievement is merely an unmasking of the so called “neurodevelopmental” disorder that has always been there. Perhaps they will justify the diagnosis on the basis of being “unmasked” in virtue of the growing mismatch as schooling progresses between expectation and capacity vs his peers. Perhaps things will be explained in terms of the current teacher being less entertaining, for ADHD kids respond better to novelty and wither on the vine of routine unless domesticated with medication. On a similar vein, we can explain how the child can sustain attention for prolonged periods on videogames and other devices, and not on schoolwork. These little machines are enjoyable. Small victories along the way of the game provides the little squirts of dopamine that the childs brain lacks in virtue of the chemical imbalance they are thought to have (though the savvy clinician won’t use the term “chemical imbalance” now the critical psychiatric community has run it out of town….…for now). Why the apparent depressive symptoms? Being hyperactive or inattentive leads to conflict that can lead to a challenge in ego strengths, a sense of knowing one lacks academic competence or comparative social successes. The child is irritable (or downright depressed looking) on account of these frustrations and failures. Psychiatrist number 3 will prescribe a powerful stimulant that is illegal in recreational use, plus/minus the antidepressant for the mood symptoms. As a footnote, I might add that the criteria from which ADHD is formulated in the child can also be seen as a reflection of immaturity per se. There is abundant evidence that the diagnosis is overrepresented and can be predicted by the child simply being the youngest in the class. The diagnosis can also be explained by a certain mix of what psychologists call the “big 5” personality traits and, in boys at least, a “pathological” mismatch between the child’s needs for stimulation and rough and tumble activity of village or tribal life and the schools demands for moulding the cog in the machine as he is told to sit for 6 hours. It is worth noting in closing that ADHD is the example par excellence of the fallacy of the response to medication proving the existence of a diagnosis. Amphetamines (and methylphenidate) have psychotropic effects on persons taking them, be they diagnosed with ADHD or not. And these effects can be notionally salutary to both in similar domains of behaviour and function. This has been known since the time of Smith, Kline and Frenchs early marketing of benzedrine and Bradleys early experiments with stimulants on the grab bag of traumatized, rejected, intellectually delayed, delinquent or basal gangliopathic children he treated. Amphetamine aids the concentration of all up to the mind it renders them only thinking they have improved cognition, this being the mind they are half way to drug induced madness. Finally, it is worth noting that the evidence does not support the conclusion of long term benefit to children of taking stimulants. Over the long term they are either useless or harmful.
Psychiatrist 4 faces an uphill task vs the first three, though let’s see if he/she can manage it anyway. To the proverbial hammer, everything is the nail. Just as there are the psychiatrists and paediatricians who are known to diagnose many, if not most, of whom they see with ADHD or depression or bipolar disorder, there are also the psychiatrists on the lookout for autistic spectrum disorder (ASD), or what might in little Jaxxsons case been called “Aspergers” or “high functioning Autism”. You see if there is the slightest sense in which he can be said to be alienated from his peers, by which we mean a subjective sense or behaviours where he is awkward, lacking in social acumen, misreading or not reading body language, response cues, irony etcetera, Jaxxson is on the radar of such a psychiatrist or paediatrician as the free spirited girl dancing in the forest was on the radar of a Salem witch hunter. This is also the case if the psychiatrist is unable to click with the child, the countertransference of alienation being projected outward from clinician to patient (or in other words, “if I don’t connect with you, the fault is not my own or tough luck. It is a diagnosis”). Our childs interest in videogames is not a bad habit or the outcome of bad parenting. It is interpreted a symbol of his autistic alienation from flesh and blood people and towards their digital counterparts. And just as the social and self-evaluative sequelae of ADHD can result in mood disturbance, the high functioning autistic child may also feel frustrated and be irritable, down in mood and even threatening suicide. He may even want to connect with others, yet cannot. The more he and his family are educated as to what ASD is and the funding support packages available driven by the diagnosis, the more they will come to take on the part of what they have been diagnosed to be (I say “they” as the childs behaviour and the parents interpretation of it are in toto one phenomenological reflective system of meaning and becoming in the family unit). In addition to opening the door to various supports, Jaxxson will likely be prescribed some medications, including an SSRI antidepressant and perhaps some medication usually given for high blood pressure to calm his irritability. If he is especially irritable and misbehaving it will be difficult for him to avoid powerful tranquilizers usually reserved for those patients with “psychosis”. These are powerful medications often difficult to wean off, and often ironically pharmacodynamically completely at odds with the ADHD medications co-prescribed. It makes as much sense as rubbing faeces in a wound of ones making and then washing it out.
In our fifth and final universe, our child encounters the final psychiatrist (though there might be many more examples). He or she might eschew over-diagnosis and be more “family” and “systems orientated”. True enough the low mood or anxiety and the various other signs and symptoms won’t be ignored. Yet this psychiatrist will look for other explanations such as the child’s symptoms being a reaction to the disconnect between parents and child, e.g. in virtue of the parents cannabis use and being too stoned to parent. The parent/s of course won’t realise this themselves and not be inclined to continue paying the psychiatrists bills if told something they do not wish to hear. After all, they will say they are only “self medicating” their own mental illness. (the term self medicate is predicated on there being a medical illness, which as I will argue does not exist in those who make the claim their illness is mental. Psychiatric diagnoses are not medical illnesses, and every drug user can be said to self medicate something within their mental selves they wish were not the case). Or perhaps the child being bullied? Or they are reacting to the parents separation? Or there may be any number of other reactions and reasons in the child’s world of relationships and groaning towards and through maturation. Usually psychiatrist number 5 will prescribe an SSRI also, if for no other reason than “pragmatism” and its use as a therapeutic object they can hold in their hand, though usually the parents want something prescribed anyway and medication is the purview of the psychiatrist. To prescribe it is a ritual of protecting the interests of the profession against the psychologists and social workers who need compete with inferior products (psychologists for example will fight back and market the utility of certain trademarked psychometric tests that only the psychologist is authorized to administer). It’s a very rare psychiatrist who won’t offer the family the symbolic power of a diagnosis at all, along with the medication the family and/or