A Psychiatric Case Study. A Sad Story

One of the criticisms that I routinely make of psychiatry is that its primary agenda during initial evaluations is the assignment of a “diagnosis,” and that ongoing “treatment” consists of 15-minute “med checks,” during which drug regimens are changed and adjusted.  The essence of my criticism is that this kind of approach inevitably oversimplifies human problems, and in practice does more harm than good.

My contentions in this regard have from time to time been challenged.  It has been said that my portrayal of psychiatry is a kind of misleading caricature, and that in reality, psychiatrists do, in fact, concern themselves with human issues over and above “diagnosis” and drugs.  This debate will, of course, continue, but I recently read an article on Psychiatric Times that has some bearing on the matter.  [Thanks to Nick Stuart for the link.]  The title is Conduct Disorder, ADHD – or Something Else Altogether?  The author is Steven Dilsaver, MD, and the piece is dated October 11, 2013.  The article is a case study of the psychiatric “treatment” of an eight-year-old boy (John).

John was brought to an outpatient clinic because of “…highly aggressive destructive behavior and sleeping problems.”

It was noted that his “…parents had been killed in a car accident when he was 5 years old, and just a year later, he had witnessed the violent death of his uncle.”  John was being cared for by his aunt, who became ill during his “treatment” and could no longer care for him.  At this point, he was placed in a facility for homeless children, where he remained for about 10 weeks.  Then he went to live with his grandmother.

JOHN’S TREATMENT

Here’s a summary of John’s psychiatric treatment as described in the case study.

On the basis of the initial interview, John was assigned “diagnoses” of ADHD, PTSD (with hallucinations), and mixed episode.

Day 1.             Rx: 2 mg of prazosin (Vasoflex); 750 mg divalproex (Depakote); 10 mg of aripiprazole (Abilify)
Day 2.             follow-up phone call
Day 8.             no changes
Day 15.           Rx: aripiprazole increased to 15mg

John was “lost to follow-up,” with no treatment, while in the facility for homeless children.

Day 111.         Rx: prazosin 2mg; divalproex 750mg; aripiprazole 15mg
Day 129.         Lisdexamfetamine (Vyvanse), 30mg at 7p.m. added to treatment regimen.
Day 139.         Lisdexamfetamine discontinued following reports of aggression.
Day 143.         no changes
Day 158.         dexmethylphenidate (Focalin) 5mg added to drug regimen
Day 173.         dexmethylphenidate increased to 10mg
Day 185.         dexmethylphenidate increased to 15mg
Day 205.         last visit.  “John had been doing well for 3 weeks.”

The above is a summary.  The text of the article makes reference to reports from caregivers, blood work, and other details.  But it is clear that the “treatment” is conceptualized as the administration of drugs, and there is no reference to any other kinds of intervention.

Final Rx:         2mg prazosin; 750mg divalproex; 15 mg aripiprazole at 6p.m., and 15mg of dexmethylphenidate (7 pm).

Final diagnoses:  PTSD; bipolar I disorder (mixed episode in remission); and ADHD-combined type.

The final paragraph of the article is interesting.

“John presented a complex clinical picture. His behaviors might have led one to suppose he had ADHD-combined or primarily hyperactive type and conduct disorder. However, there was a strong history of trauma and an affective disturbance that included not only irritable but also depressed and euphoric mood along with grandiosity, and the results of the structured interview indicated that he formally met the criteria for both PTSD and mixed episode at presentation. If not for the use of a structured interview format, the features defining these disorders might have been missed and the child treated only for ADHD. His final diagnoses were PTSD, bipolar I disorder, mixed episode in remission, and ADHD-combined type.”

I think most of us on this side of the debate would agree that “John presented a complex clinical picture.”  But what is clear from the article, and especially the final paragraph, is that what the author meant by that was that John “had” more than one “diagnosis.”  It is also clear that “treatment” consisted of prescribing drugs and tweaking dosages.

The truly sad part of all this is that Dr. Dilsaver appears to believe that this “treatment” is what John, with his extraordinarily troubled history, needs.  We’ll probably never know what happens to John.  But we can be reasonably certain that these stigmatizing and disempowering “diagnoses” will follow and define him for years – perhaps for life.  We know that he will be identified by various official and semi-official figures as someone who needs to be “on meds.”  We know that attempts on his part to discontinue these dugs will be met with resistance.

We can’t predict the future, but, I suggest, the odds for John are not great.  At age 8, with his world shattered in an unbelievably horrific manner, he has been shunted into the marginalized siding of psychiatric chemical restraint, from which he may never escape.  If he hasn’t already, he will probably soon be given a disability “award” with all the implications of damage and reduced expectations.

This post is not just a criticism of Dr. Dilsaver.  After all, he’s a psychiatrist, and this is what psychiatrists do.  In fact, because psychiatry has been so successful in marketing and promoting its so-called illnesses, Dr. Dilsaver would have been open to censure and lawsuits if he had not taken these kinds of actions.  Until these professional, legal, and cultural pressures are changed, we will see more and more children “treated” in this way.

Part of the irony in this matter is that it is clear from the article that Dr. Dilsaver believes he has done good work, and seems proud of the fact that he didn’t miss the PTSD and bipolar “diagnoses,” and that he “treated” these “illnesses” successfully.

Incidentally, according to GoodRx, a month’s supply of John’s final drug regimen costs $779.  (prazosin $8; divalproex $17, aripiprazole $712, and dexmethylphenidate $42).

  • Nick Stuart

    Thanks Phil for highlighting this barbaric situation. I suffer from Entropic Empathy Disorder (EED) for which I have to take strong medicine. I hope more people would recognise this disabling condition.

  • Francesca Allan

    Yeah, Nick, me too, but that’s not by prescription 🙂

    Phil, thanks for posting this very depressing (and very believable) case study. You’re quite right. Diagnosis is done in a few minutes yet effectively becomes a life sentence. Try to talk about what’s bothering you and the shrink at best might nod while he’s got his trigger hand over the prescription pad.

    I really don’t know what it’s going to take.

  • Nick Stuart

    Stopping child abuse would be a start. But that ain’t gonna happen any time soon is it? But still.. I will continue on a futile quest just in case.

  • Nick Stuart
  • Nick Stuart

    http://theness.com/neurologicablog/index.php/how-electroconvulsive-therapy-works/

    Steven Novella is a dangerous man. I think Yale university should know that he is using their good name to in order to subvert science.The CNS should expose him.

  • Phil_Hickey

    Nick,

    The truly awful tragedy is that this is the kind of “treatment” our politicians have in mind when they call for more mental health services. As far as I can see, there is absolutely no limit to the extent to which psychiatry is willing to expand its net.

    Thanks again for the link. The clinical dispassionate tenor of the piece somehow made it all the more horrific.

  • Phil_Hickey

    Francesca,

    It’s going to take enough of us saying it over and over. Once people see it, they can’t stop seeing it, because it’s so flawed and destructive. Keep writing.

    Best wishes.

  • all too easy

    “But we can be reasonably certain that these stigmatizing and disempowering “diagnoses” will follow and define him for years – perhaps for life. We know that he will be identified by various official and semi-official figures as someone who needs to be “on meds.” We know that attempts on his part to discontinue these dugs will be met with resistance.” Phil
    We can be reasonably certain that his diagnoses saved his life in the short term. Learning an illness interferes with daily functioning is liberating and empowering. The diagnosed is not evil, just ill.
    We are all identified at times by others in descriptive terms that may be quite negative and harsh. Pimple-faced, stutterer, braces-face, 4 eyes, carrot top, etc. If and when John chooses to withdraw from meds, no one can stop him, no matter how hard they try. In the meantime, those awful meds are giving him a chance to work through the practical, daily, nitty-gritty issues that result from experiencing such trauma.

  • all too easy

    It will take proving that millions whose lives are saved daily got it all wrong. It will take removing meds from the marketplace and watching those desperate folks thrive. Those things will never happen, thankfully, and kooks like Phil will be rightly viewed by everyone as a jealous practitioner who never helped a single client.