Musings of a phenomenologist

Science, psychiatry and random musings

But she’s a professor!

Posted by soveda on December 19, 2008

Thanks to Ben Goldacre’s mini blog I came accross this story. It’s a worrying story for me in several ways, the diagnosis by letter being one.Now if I were to suggest that appendicitis could be diagnosed without seeing the patient and relying only on second hand information from a source with no medical background I would be laughed at, and rightly. So why do we think that severe mental disorders can be diagnosed without seeing the patient?

This article suggests that from a letter a young man can be diagnosed with “severe depression” and “acute paranoia”.  You can see for yourselves the comments suggesting an alternative diagnosis of OCD be considered so I won’t rrepeat what is written other than to say I agree it should be part of the differential in this case. I’m more interested in the diagnosis as given.

Who is Tanya Byron, sorry, Professor Tanya Byron?

Well we can see from the above links that she is a clinical psychologist who specialises in child and adolescent mental disorders and behavioural problems. She is a proper doctor with a PhD from an accredited and respected university. She is also a media pundit and author. I have worked with a few consultant clinical psychologists and they have all told me the same thing: “we do not diagnose”. Professor Byron has (or seems to, there may be editorial influence of course) and with a major mental illness.

What she is describing in her reply sounds like persecutory delusions in the context of depression. The term “paranoia” in clinical psychiatric practice has historically been interchangeable with “delusion” thus “paranoid schizophrenia” means schizophrenia where delusions are prominent.

If this young man does have delusional beliefs and depression he needs to be seen urgently by psychiatric services and I hope that Prof. Byron contacted the family urgently if she felt this was the case rather than just waiting until the publication of her article.

This:

We are still some way from really supporting those with mental illness in a holistic and person-centred manner. There are splits among mental health professionals, who range from those who adopt a more medical model, ie, assess, diagnose, treat (usually with medication), to those who believe that diagnoses are meaningless and dehumanising and it is better to understand the individual’s experiences of mental illness rather than adopt a “diagnostic herd mentality” that results in “mentally ill patients” rather than “people with mental health problems”.

did get my hackles up, if you are a regular reader of my rants you will realise that I am very keen on breaking through stigma but this seems to me to just promote the perception that there are two diametrically opposed camps when the reality is (probably!) that most clinical practitioners hold a position somewhere in the middle.

I find her assertions that “paranoia” is best treated unsing primarily CBT interesting but I would like to see the data.

Having said I wouldn’t comment on the possibility of OCD I find myself unable to not do so…

The facts as presented are:

  • “fear” of knives
  • Thoughts/feelings he is going to harm someone
  • belief that he has stabbed someone
  • Guilt and self condemnation

These thoughts are unpleasant to him and alien to his normal self (ego-dystonic). Now without actually interviewing the lad does this sound like paranoia or obsessional thoughts?

I’m sure that Professor Byron (professor of what by the way, all I can find online is a reference to being the Chancellor of a university) is a competent clinical psychologist but I do think she is risking her professional status by commenting on things like this without caveats.

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11 Responses to “But she’s a professor!”

  1. jdc said

    Nice piece soveda. Your first para grabbed my attention, as “distant diagnosis” is something that’s long concerned me. I almost think that that element of the story is more interesting than the suggestions that she has misdiagnosed. I don’t think she should even be in a position to misdiagnose people by letter or email, as I don’t think anyone should be providing distant diagnosis.
    Like you, I’d seen the story in the BadScience miniblog and gone to read the advice Tanya gave. Was interested to note that several commenters pointed out that there was much in the letter that pointed to OCD. People are bound to make mistakes in distance diagnosis and this looks like a good illustration of why it is such a bad idea.
    I’ve written before about, e.g., the role played by psychologists on TV shows such as Big Brother being in conflict with the ethics codes of the BPS – this is another example of iffy behaviour by psychologists/psychiatrists, and yet again it is connected to the media. If you whore yourself to the papers and/or to television then I think you run the risk of trivialising your work and of being tempted to do things you wouldn’t normally do in the course of your work, things that would normally be considered “not good practice” or simply inappropriate. Raj Persaud wasn’t averse to distant diagnosis and there have been others less well-known who have conducted distant diagnosis too.

    Cheers,
    jdc.

  2. Without meeting him you don’t know what it is. This letter should never have been published. But just to play the distant diagnosis game: it’s classic melancholic depression (“He has just been home and his mood was very depressed. He became quite morose near the time when he had to go back, and he is very thin, not able to eat properly.”). Obsessional thoughts (ruminations) and guilty beliefs, bordering on delusional, are common in melancholia. The parents have noticed weight loss, that indicates depression and probably melancholia. I’d be interested to know how he’s sleeping; waking up at 4.00 am I bet.

    “Paranoia”, on the other hand, is nonsense. Nothing in the description of his case suggests that. Byron’s reasoning is that “persecutory paranoia (the most common, and what your son seems to have): a person believes that those around him are enemies, bent on harming or killing him (feelings that lead to his belief that he may need to stab someone to protect himself)” is clearly crap because the whole point about this case is that the patient is aware of, and distressed by, the irrationality & obsessive nature of his feelings.

    Diagnosing him as paranoid could be very damaging because the family might read this and think that their son believes them to be enemies and might actually stab them. Which, if he were psychotic, might be possible; as it is he sounds obsessional and in touch with reality, meaning that there is no risk.

    The rest of the letter is just a crap review of the literature on psychosis, essentially. “Stressful events can also trigger episodes, as can high levels of expressed emotion in people who are close.”, indeed.

    He might have OCD, but if so he is certainly depressed as well (weight loss!), and I bet the OCD symptoms would resolve when the depression is treated.

  3. soveda said

    Distant diagnosis is best left to watching casualty or er…
    There is no time frame to the symptoms, it’s impossible to say whether the depressive or obsessional symptoms are primary or secondary. I’m not suggesting that ocd is the only diagnosis that fits the facts as presented, he I did I’d be guilty of the same thing as the good professor.

  4. CaptainSensible said

    Hi soveda,

    I think I can explain what she is getting at; I’m not playing devil’s advocate (I still think she is a media whore!), just explaining why some clinical psychologists (and patients) are not that keen on diagnostic labels. Unfortunately, her wording does suggest that clinical psychologists and psychiatrists are in some kind of opposition whereas in fact they are merely trained to treat different aspects of the same individual’s problem in different ways.

    ‘Holistic’ is one of my favourite words and is extremely precise/useful, but it has sadly become a (positive) perjorative term that is associated with woo instead of something that merely refers to a macroscopic approach to any subject. God only knows why, but it is a shame.

    However, it is true that what might be appropriate and necessary for a patient (i.e. diagnostic labels) in a psychiatric context might not be appropriate and necessary in a psychotherapeutic context. I discuss things in a scientific way with my psychiatrist (talking about various drugs and labels for various mood states/cycles etc.), but terms like ‘dysthymia’ etc. don’t really have any relevance to psychotherapy.

    The mentally ill can easily fall into the “I have a name for my pain; therefore, I feel better trap”. Of course diagnosis is useful (reading about aspergers [which I may or may not have; self-diagnosis is the other trap related to labels & terminology] has been a revelation; it has the potential to explain a lot), but it marks the beginning of the (long & hard) psychotherapeutic process instead of the end. It might involve a bit of doublethink or compartmentalisation and requires self-discipline, but I think mental health patients should be encouraged to leave their labels outside when they go and see their clinical psychologists/therapists and pick them up again when leave (just as you take off your shoes before entering the main living area of most Japanese homes).

    I think person-centred therapy (PCT) or existential therapy of counselling psychotherapy or ‘talking’ therapy is great. Unlike the Freudian stuff (which is bollocks I think, but it does make sense to some patients), it makes sense (to me, anyway) and its founders were/are honest/brave enough to admit that psychotherapy cannot solve all problems (which is why Otto Rank broke away from Freud I think) and that some anxieties are inevitable and possibly healthy. Unlike Professor Brown though, I do not see the difference between psychiatry & psychotherapy should be seen as a split or an opposition. It bugs me when supposedly intelligent individuals promote such fundamental misconceptions (not as bad as qualified medical doctors/GPs defending homeopathy [they should be struck off], but almost)

    Regards

    CS

  5. soveda said

    I agree that diagnostic labels are not necessarily useful and are not needed for much of the talking therapies but I do take issue with the motion that you can’t work in a person centred manner he you give someone a diagnosis. A diagnosis is just shorthand for a cluster of symptoms that may predict the future course of someone’s mental health. It also allows access to services that are specific to the diagnosis, e.g. specialist clinical psychology services for post traumatic stress disorder.
    It is attitude rather than a diagnosis that is the bar to holistic treatment.

  6. BobP said

    Take a step back for a second.

    What we have in the Times is:
    – an edited version of
    – a letter written by parents
    – about their son.

    I’m suspect it’s a fabrication. What parent, confronted with a disturbed son, writes to the Times as their first line of support?

    If it’s not a fabrication, then its a third hand report of symptoms. Not a good basis for diagnosis!

  7. soveda said

    I do wonder if it is a fabricated letter but such a letter would fit the diagnosis better surely…

  8. CaptainSensible said

    I didn’t mean to imply that there was something intrinsically wrong with diagnostic labels. I’m quite happy to talk about dysthymia and OCD and cyclothymia and everything else in the DSM-IV. My point was that diagnosis is the only the beginning, and that it is possible for some people to expect the diagnosis/the end of uncertainty to be a cure in itself or would talk about nothing but diagnosis and the related terminology as a form of avoidant behaviour. I don’t think diagnoses are demeaning or reductionist (falling for that one would make me like thirty something career women who resent being told about their declining fertility by the patriachal medical profession).

    I often discuss diagnoses with my therapists (we’ve been talking about nothing but aspergers and other developmental disorders for the last couple of months), but they often have to correct me/steer me back into ‘relevant’ territory when they detect that I am (not necessarily intentionally) concealing something or avoiding something. If her suspicions about my having (what would be mild/borderline) aspergers is correct, then that will explain a lot. However, it will also be the beginning of a lot of work if I’m to overcome some of the obstacles that it has put it my path; it’s nice to know that they were always there or that I didn’t put them there, but there are still there and causing a lot of problems.

    I’m not anti-psychiatry at all, and I’m miffed with Prof. Byron for phrasing her comments in such a way as to imply that psychiatry and psychology/psychotherapy exist in opposition to each other instead of being complementary. I agree with you entirely about there being nothing wrong with a PCTherapist either giving you a diagnosis (in something that they are qualified to diagnose) or discussing it; my point was that diagnosis (which can be initially positive in an explanatory power sense) should be seen as the beginning of something and not the end of something from the patient’s point-of-view. Tanya seems to think that the diagnostic process and the treatment/healing process (which involves a lot of necessary PCT listening and tailoring to suit the individual) are odds with each other when they are actually just two different stages of something which constitutes the best way of dealing with people.

    Tanya is understating the value of diagnosis whereas I’m trying to explain how the value of diagnosis can be overstated, and often by patients and not in their long-term interests; they need to leave the diagnosis at the door to some extent so they can focus their energies on dealing with whatever it represents. I’ve no problem being part of a herd or being labelled or being seen by MHS professionals as someone ‘with a mental problem’. I think it is healthy in fact; being able to think about and discuss your condition is scientific/objective terms is extremely beneficial.

    When people ask me about my illness, I explain it to them in strictly medical model terms (using mood graphs to show the difference between unipolar disorders and the various degrees of bi-polar disorders and explaining that how mental illness is not that different from physical illness [although it has physical symptoms obviously]; the difference being that the ‘organ’ being affected by mental illness [the mind I suppose] is a bit more illusive/hard to pin down than the lump of grey stuff in your head that generates it). People are much more positive towards this (and often impressed by it) than someone telling them how awful their life is.

    So I think Tanya is wrong because I believe MHS users need to develop a doublethink/compartmentalised mindset where they are both part of a herd and unique individuals with unique problems and unique life histories that require unique solutions (to be developed by the individual with the help & guidance of a PCTherapist. However, I also think there is a fine line between trashing the value of diagnosis and over-emphasizing the effect (not necessarily the importance) of diagnosis in a way that distracts MHS users from the work they need do in therapy.

    Am I making any sense?

  9. soveda said

    Not wanting to stop an interesting discussion in full flow but I think we agree on this topic!

  10. CaptainSensible said

    Heh… I hope that isn’t psychiatrist code for ‘shhhhhh’ 😛

    Enjoy Xmas.

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