I LOVE Portlandia! It's just the right combo of WTF and "there's no way these people are serious"

Enough sitting on the sidelines, especially with such a provocative topic.

What if I were to say, as one practicing in the field, that one of the major misconceptions of psychiatry is that we have 'diagnoses'? Depression, schizophrenia, bipolar disorder, etc. are behavioral syndromes assumed to have common, underlying pathophysiologies. Recent research suggests that there are a multitude of potential causes and contributing etiologies. Biological, psychological, social, and spiritual factors all contribute to the development and presentation of mental illness. What constitutes a mental illness is also related to societal and cultural norms (hysteria, anyone?). It therefore makes it hard to have a 'false positive' or 'false negative,' as there is no way for me to know what a 'true positive' actually is.

I believe that it is better to think of mental illnesses as being analagous to other symptoms like pain, as opposed to specific diagnoses like appendicitis. Psychiatric treatments are also symptom based, as opposed to being specific to a particular etiology. When I see a patient who tells me that they are 'depressed' that actually has little meaning for me until I can understand what their experience is, and how it limits their functioning and quality of life.

What constitutes 'bad psychiatry,' anyway? Most people would probably think that drugs with terrible side effects, or restricting people's freedoms is bad psychiatry. Many drugs used to treat rheumatologic conditions are quite toxic to other body systems, but they are considered good and appropriate treatments for arthritis or scleroderma. Acetaminophen can cause liver failure, ibuprofen can cause kidney damage.

I'd suggest that 'bad psychiatry' be defined as a lack of willingness to understand people and meet them in their suffering. I can offer a number of useful tools that may (or may not) be helpful for any particular patient, but it is in collaborating with them that I can figure out how I can be useful. And sometimes, there are things that I can't fix or undo.

Science will always continue to change and reinvent the way that we think of illness and disease. Humours, vapors, ether, phlogiston, fenestration, phlebotomy, leeching, and lobotomies were all cutting edge science at one point and taken as being unalterable truths. Antibiotics were going to eliminate infectious diseases, not create resistant 'superbugs'. Thalidomide would (and does) reduce nausea. It seems that science is always limited by hubris.

I doubt that all mental illness will ever be explained by neurochemistry, and even if it is, the experience of suffering, not a deficiency in serotonin, is what drives patients to seek help. That's why I do what I do.

I agree with Jess' point that people see their emotions and thoughts as somehow more intrinsic to themselves, and the fear that a psychiatrist can change that with drugs, electricity, or therapy, is a threat to their very identity in a way that losing a leg isn't.

BTW, Paras, when are you coming back?

"I think therefor I am", not I still have two legs and two arms therefor I am. I think this sums it up for me. I think the idea of a doctor telling you, that who you are is wrong, or faulty, or can be fixed( not really sure how to word this sentiment), is terrifying.

This shit just got serious!

I think bad psych work is scarier because your brain affects who you are, and how you perceive yourself, which to me is more important than how many limbs I have, but maybe I'm in the minority there. I mean, you can use psychiatry and psychologists to help you get over losing a leg. You can use a surgeon to help you get over a lifetime of depression. Unless they want to start doing things like adding useful third arms or whatever, but that's another argument for another day.

I also feel (not believe necessarily, just feel) that there would be more opportunity for false positives and bad diagnoses with brain work than with the phsyical workings of our bodies, and that's one of the scariest things about medicine to me, more scary than missing something that's actually wrong, which I know happens all the time across all fields.

I disagree with Matt's assertion about people believing that psychiatry mistakes are scarier than surgical ones.

I do agree with what he wrote in his last paragraph. What I was thinking while I watched the video was that people with mental problems are sometimes, but not always, incapable or less effective at establishing and maintaining social bonds with other people. At the end of the day, if I can feel like I can know and interact with someone with some degree of predictability, then I am more comfortable accepting other things that may be unusual about them. I think this is where the stigma of psyc patients comes from, and consequently the fear around seeking psychiatric help.

To respond to your last question, Paras, I think that is a large part of the answer. Even when it comes to, say, vaccinations, where the medical community is completely united in their assertion that vaccines are good for people, there is still this undercurrent of popular resistance to that.

There's a sociological theory called 'sick role theory' which states that people can get out of their usual social responsibilities (such as going to school or work) without consequences if they're sick and seek and follow medical advice (which can amount to adhering to the general opinion that you should sleep lots when you have the flu, even if you don't go to the doctor). It's obvious, of course, but what was interesting was that the writer (whose name I've forgotten) specifically said that this did not apply to mental illnesses, since patients always have a better understanding of what's going on with them mentally than a outsider, even a professional one. He was writing back in the 50s (I think), when people tended to respect professionalism more than they do today. Now of course, people think that their opinion is as worth considering as their doctor's, even when their problem is objectively measurable. So I think it's not just their willingness to admit ignorance, but also a sense that, even back in the fifties, psychiatrists are more advisors than supervisors in care. And now, people are clawing back as much power as they can from professionals, generally. Our thoughts and emotions are much more an intrinsic part of our identities, so we are more reluctant to turn even a small amount of power over those aspects of ourselves over to someone else than we are when it comes to a bad knee or something. Movies play on that fear, I think, rather than being primarily responsible for creating it.

Hmm. That got long and ranty, considering I was agreeing with people.

In the hope of starting a discussion, why is wrong psychiatry scarier than wrong surgery? If someone amputates the wrong leg (it has happened) is that not a horrifying outcome?

Is this just a problem of psychiatry admitting uncertainty while the rest of medicine (erroneously) boasts absolute certainty?

That's awesome Par. What came to my mind is the following:
-Yes, psychiatry DOES have an imperfect history, as do all fields of study, but getting psychiatry wrong is way scarier than doing, say, an un-sterilzed surgery, or getting physics wrong.
-It's hard to trust psychiatry all the way because of this, and also because we still don't understand the brain 100% yet, so how can psyciatrists assure us that we're absolutely without a doubt in good hands? And also because we know so little about the brain, we can imagine all kinds of horrific things potentially happening to us, but we know what happens to legs and arms and stuff pretty clearly.

And I'm not at all slagging psychiatrists but I think that's why people still associate psychiatrists with (like he said) paranormal and paranoid ideas. The brain is still a bit of a mystery, so people lump it in subconciously with other mysteries.

I think mental problems are treated and seen differently than other diseases because it limits your ability to communicate with people in a "normal" socially established and predictable way. If someone's brain chemistry differs enough from your own, they're practically an alien. Not the same as getting, say, tetanus. It's disconcerting in a way that physical ailments aren't.

You say that now, Jess, but once you get lockjaw vigilantes are what you'll want to save you.

Tetanus is complicated, because it's not the bacteria that's the problem but rather the toxin. The toxin binds irreversibly, so neurological damage that results from bound toxin doesn't really subside, but you can give people 'tetanus immune globulin' (ie. antibodies against the toxin) to mop up unbound toxin.

Still, it's a crazy diagnosis, and certainly not what I expected, but I at least found out enough when I examined him that I got him to the neurologist.