Leaving Psychiatry. J. R. Ó’Braonáin. M.D.
to thoughts of suicide. Lacks insight into his psychosis and non-compliant with treatment (i.e. denies having a mental illness and does not take his medication). Fully conscious”
Diagnoses; It is not at all uncommon to find psychiatrists with genuine disdain for the DSM or the ICD 11, these being the diagnostic nosology in use throughout most of the world. Often they might parrot the usual party line that such diagnostic manuals or criteria are “just guidelines” and be critical of some diagnoses, choosing to value the criteria as enunciated in the DSM for research purposes and consensus of what makes for a name for purposes of inter-practitioner (and often international) communication. Occasionally one might encounter a psychiatrist who would rather the DSM go away. But what is extremely rare is the psychiatrist who attempts, in practice, to do away with the DSM entirely and explain the patient as a formulation alone, or a narrative akin to that one might read in literature. However much a psychiatrist might pretend to be “anti DSM”, when taking the history their mind is invariably ticking over as to what DSM and/or ICD 11 checklist criteria are included and which are excluded. All psychiatrists almost always implicitly use it and almost always are explicitly required to. To not do so and not do so well for many years would render it impossible to complete training and enter the priesthood. If we could conceive of a modified Turing test where the robot was to take the history and record the mental state exam, each congruent with the resultant being diagnoses as per DSM or ICD 11, then this robot would be indistinguishable from almost every psychiatrist I’ve ever known (the exception being the one I am not permitted to be).
Formulation; Formulations are explanatory little statements of a few paragraphs, linking the patient’s presentation with the symptoms and some speculative link to a “theory” of mental illness most applicable to the case. Formulations are a game for true believers of the theorist and sophists alike. The five different explanations of the child’s case (vide supra) are crude approximations of formulations, to which one might add a comment on what may foreseeably make the patients mental state worse in future, and what strengths and resources the patient can draw upon. A tongue in cheek example of a crude formulation for now might be this fiction…
“Sigmund presents with suicidal ideation symptoms and the full suite of symptoms consistent with a diagnosis of major depression. The current episode seems to have been precipitated the revelation his brother likely had sex with his stepmother, Sigmund being angry he himself did not succeed in the conquest, this anger introjected (i.e. turned inwards) and transmuting itself into the depressive symptom complex itself. An additional contributor to his depression may well be the ambivalence Sigmund has towards his father, enjoying the fact his father qua Laius object has been slain, this satisfaction not sufficient to overcome the punitive superego against his psyche in response to the enjoyment itself. Thankfully Sigmund is functionally quite strong, has an excellent capacity for insight and is agreeable to taking the therapies prescribed (principally opium, along with, of course, analysis), though there may be countertransference issues with the therapist whom Sigmund believes is of inferior mind.”
Developing a robot to construct a formulation would not be as easy as developing one which could take a history, document a mental state exam and narrow to the point of choice from the smorgasbord of diagnoses in the DSM or ICD 11. Nonetheless there are now artificial intelligences that are amply up to the task. A program has now been developed to replace journalists, beginning with the first paragraph it can mine the internet and complete the article from there. Psychiatric formulations are the same, fake news that might be real, and real to the trainee to the extent they might dialectically defend its use as applied to the patient (as opposed to it being the truth of the patient), and real to the patient to the extent it is convincing. No one really cares how or what the formulation is. Providing it is done well, you could complete two or more disjunctive formulations and choose your favourite. One can formulate according to a biopsychosocial, or object relation orientated or Freudian or systems minded or Jungian or existentialist or Eriksonian or anywhere up to another dozen other theorists/theories I can think of. Psychologists often do formulations which are almost entirely bound up in numerical scores of psychometric testing, and appear more like summaries of finance reports rather than something about a human being living amongst other human beings.
Many formulations nowadays are banal statements composed of the “5 P’s”, i.e. the presenting complaint, the precipitating factor, the predisposing factors, the perpetuating factors and finally the protective factors. A fictional example that may match many patients
“Krystyll, a 20 year old mother of three (all children are at all times in their grandmothers care and the fathers are nowhere to be found) arrived in the ED via ambulance after over dose whilst having an argument with her boyfriend, this within the context of intoxication with alcohol and cannabis, and on background of multiple past overdoses. Krystyll has a genetic diathesis (i.e. family history) of manic depression. Thankfully Krystyll is help seeking and well supported by her grandmother, though has limited other supports having become estranged from her parents and the fathers of her children due to drug use for which she is pre-contemplative to change. I’d speculate that much revolves around her early attachment, this being anxious avoidant.”
Notice how I cover the “5 P’s” without actually using the “P” words. When I was training and this method of formulation was coming into vogue, explicitly stating the 5 P’s was considered insipid and lacking sophistication, I can only conclude for reasons of a drive to dissimulation, appearing to be something literary, something greater and tailored to the individual, while being something systematized and technocratic.
Insomuch as formulations are a choice of theories, they are the art of the sophist and a pretence to sophistication, and nothing more than pastiche. The greatest authentic formulators were Dostoevsky and Shakespeare. Read their works, their descriptions of people. Neither of these were psychiatrists. Psychiatric formulations are, in comparison, quite embarrassing really. They are, like the symbolism in the cover of this book, a taking apart of a beautiful thing, subsequently unable to put it together again whilst horrifyingly thinking they have all the same.
Treatment; This last step is rather easy, and I could teach any junior doctor the basics in a few weeks of on the job training. Start with the guidelines into the disorders as published by the local guild machine APA (USA), CPA (Canada), NICE (UK), RANZCP (Australia, New Zealand) etcetera, and apply this to the patient. For all of the many pages and for all the appeal to expert judgment, these guidelines are just glorified flowcharts. Actually it is simpler still for the psychiatrist, as most will have their favourite few drugs or drug combinations for each of the disorders, be it the so-called antidepressants/anxiolytics, mood stabilizers or antipsychotics. For example, take the depressed patient. If the depression is mild start with CBT. If it is moderate add CBT to the SSRI. If unsuccessful move to a tricyclic, if unsuccessful still augment with lithium or antipsychotic. The end of the line if all else fails is ECT or an MAOI, or both
Granted the doctor need be aware of dosing considerations, if and when to test serum drug levels, exclusion of organic causes of depression (i.e. medical causes of depression such as underactive thyroid), when and how to switch medications and so on. Yet this is not too daunting, also just a memorization or reference to flowcharts. The psychiatrist might be able appear more erudite by justifying specific medication choice on the basis of what receptor systems they act upon and which they do not. These are by and large convenient stories, mirages of oasis that vanish when one looks closer at the literature. The psychotherapy is more often than not outsourced to psychologists as psychiatrists take upon themselves a managerial mantle, this being convenient for psychiatrist is by and large as neither competent at, or interested in, the “talking cure”. If they are, they will have their pet little approach that is also easy to learn in practice. Surely this fact is not controversial.
My example is a deliberate one, for it is worth digressing at this juncture to hurl grenade at the myth of the power of so called antidepressants, these also often marketed as first line for anxiety. Once again my little spiel will be unreferenced. Suffice it to say for now that these agents correct no chemical imbalance in the brain, for no chemical imbalance has ever reliably been found, nor any other biological pathogenesis accounting for any but a tiny subset of depressed (or anxious) patients. It is the same also for schizophrenia. What these medications do is run the risk of creating a chemical imbalance,