So for now, how we start is I start off with a point and then we just ramble. Yeah. Hopefully good stuff comes to it. Okay. So my point today that I'm starting with is I'm just identifying a problem that I see. And the problem is about bipolar. And the point I'm making is there's a problem that in our training for psychiatric residency is, you learn basically all your initial information on inpatient psychiatry.
Inpatient psychiatry, typically we're talking about involuntary cases, very severe cases, cases that can't be managed, that they're... typically an acute risk to themselves or others. The problem is that you build your foundational psychiatric knowledge on the most severe cases. So I see a lot of practitioners who think that if it's not severe, near psychotic bipolar, it's not bipolar.
It's a problem, right? Which is funny because I also think it's a strength. I would say that the majority of practitioners out there, non-psychiatrists who are applying any kind of diagnosis, putting forward any kind of diagnosis out in the field, they don't have enough acute setting experience. You know, you do need to actually see how severe something can get when it's a more biological medical condition, something outside of someone's arena of control, something that happens to them, right?
You don't necessarily see that on the voluntary side. But it's as you say, there's a problem. You don't see the nuanced bits. You don't see people when they're relatively well. You're not seeing people when they're sort of euthymic, sort of on their normal state between episodes, which happens, right? So people think that it's a bigger problem with DSM in that it's, I think, in the last few years, gotten trainees and even some psychiatrist to believe that the output of what a patient tells you or what they're doing is the same thing as the disorder rather than some kind of underlying problem
all right i missed i missed that last point what should i repeat it or Say it differently. The output is... Sorry.
Yes. Okay, so this is something that we're probably going to be repeating a lot, but output is not the same as underlying process. Oh, okay. What someone is doing in front of you, what they talk about, what they tell you is or is not happening is not the same as whatever is going on inside of them that's producing that. And properly, we're trying to identify what is going on inside them.
What's the underlying process? And I think that's the logical error that happens when people say, well, I don't see the mania in front of me. That's not bipolar disorder. Really? Did you observe this person across the entirety of their lifespan? No one can do that. So that's the error, right? There's an underlying process, and that's what we're trying to get to.
Okay. Now, that brings me to my second grievance, which could have been my first point, which is that, and I had this happen all the time at residency, people think they can diagnose bipolar in a 15-minute interview. And I had so many times where, for me, the... All that matters... Not all that matters. The main thing that matters in bipolar is collateral. There were so many times I'd have an interview with a patient, and they would come off as cluster B, and they would be using primitive defense mechanisms, and...
Then I would, you know, come out and I'd be like, I think this is, you know, I'm not sure what this is. And the person would be like, what are you naive? This is clearly just borderline. This is clearly cluster B. And so many people thought that in talking to someone in 10 to 15 minutes, they could see that they weren't talking rapidly, that they weren't psychotic and say, that's not bipolar.
That's just, they're clearly borderline, clearly cluster B. Yeah.
Well, what's funny is that, and I know, by the way, that there's going to be a lot of There's going to be angry responses to this, but I think I can diagnose bipolar in maybe 20 minutes, possibly less, depending on how obvious it is. But what you're referring to there isn't diagnosis of bipolar. You're referring to exclusion of bipolar as a diagnosis, right? People think they can exclude something in 50 minutes, and it takes much longer to exclude a diagnosis than it takes to recognize a diagnosis.
Okay.
So you're being provocative. You're saying you can rule in the disorder. You can't rule out the disorder.
Exactly. Exactly. Yeah. Well, you know, I think we're making the same point, but you'll find I'm pedantic.
But so,
yeah,
my point is that someone who their clinical appearance is perfectly borderline personality disorder, perfectly, you know, the interpersonal thing is that they're using defense mechanisms that are associated with cluster B personality. And what's going on is a bipolar process. And that the bipolar isn't manifesting as rapid speech, as, you know, all the things that you typically associate with bipolar. It's actually manifesting as a primitive personality structure.
Yeah. And well. That's a complex way to put it, I would say. Simplify it for us. Can a bipolar disorder manifest as a primitive personality structure? I'm going to try to clarify that. I basically agree with the fundamental point. But properly speaking, that's not the bipolar disorder manifesting. I would say that it's the bipolar disorder manifesting Okay, let's pretend, let's stipulate that, yes, that person who seems borderline actually has a bipolar disorder somewhere in there.
What we're seeing is that the bipolar disorder is probably aggravating their underlying personality functioning, right? They're manifesting a lot of those dynamics because they're under a lot of stress or because they're regressed or because they're acutely and supremely irritable or paranoid. Right. Those are things that we can trace back to and say, well, that's a bipolar disorder issue. Those are things that we can see in hypomania, mania and mixed episodes.
But I'm also going to say, at least in my opinion, people with mature personality structures at baseline, even in mania, will present a little differently. They won't necessarily seem the same way. But this is the broader point. The more important point is that the presence of one disorder does not exclude the presence of another. And I know a lot of practitioners don't like that because they care about parsimony.
OK, you can see I think it's Dr. Alan Francis posts about this here and there, you know, among other things. But you want to try to explain somebody in as few diagnoses as possible. But forcing yourself into that can actually cloud your judgment. It can Cause you to say, well, I've identified one thing, therefore there are no other things happening. And that's just not realistic, right? People can have as many problems as they have.
Now, but you have to understand the desire for parsimony because even if the DSM doesn't operate under this, naturally as humans, we assume there's an underlying, I guess similarly how you view a pathology in medicine, that there's an underlying pathology and that the name and how it plays out matters less than what's going on under the hood. So depression, the fact that you can, if someone has six diagnoses, it feels like under the hood, there's nothing that makes sense.
Yeah, I mean, it gets a lot more confusing, right? But I'm not even getting into the realm of six diagnoses, or I'm getting into the realm of two or three. And it's actually illogical to say, well, they have one thing, they probably don't have another. I've already explained everything about this person with this one diagnostic concept. And It isn't a DSM, by the way. The DSM wants us to say that if we make a diagnosis, it's not better explained by X, Y, Z, right?
Yeah, details the conflicting ones. Explicit instructions in every diagnostic set of criteria for us to do that. But let's draw a parallel to physical medicine. Physical medicine. It's all physical medicine to some extent. But let's draw... a parallel to a different branch of medicine. Let's say someone comes in and you've diagnosed a pneumonia, right? You've percussed, you had a little chest x-ray, you know, you saw that they had signs of infection in the blood.
You can hear the pneumonia with your auscultation using your stethoscope. Okay, does that mean they don't have a lung cancer? What if the lung cancer early on is creating the setting that makes it more likely for them to have the pneumonia, right? It's just an example. Diseases do come together. Diseases can come separately together. We need to be open to that, even though we do want remaining parsimonious.
So I guess what I'm looking for is balance on that front.
That was a perfect metaphor for the thing we were describing. But there is an issue with the overall balance. The problem is with the lung cancer and pneumonia, there are two things that if you looked, there's some physical thing occurring that you can identify as the pathology. So the pneumonia, if you were to buy up, you know, if you were to, you could find out that there was a specific organism involved.
And then the lung cancer, you could biopsy and say that there's a cancerous process involved. Now, when you get a – you'll get patients that are MDD, OCD, ADHD, blah, blah, blah, blah, blah. There wouldn't be these physical things that you could find that the person would have all the – That's right. We don't have biomarkers. But we'll never have them because it's not – to me, there's not an underlying thing that's occurring.
Oh, really? You don't think we'll ever have biomarkers? I don't think we'll ever have biomarkers. Of course we're going to have biomarkers. No, I think I'll say the way that the DSM is structured and how we diagnose will never have use. I don't, I have to think about how I wanted to put out my press conference.
That's all right. Um, I think, I don't, I don't think it's possible for us to know what we're going to know. Um, And I think it's always possible we're going to find biomarkers. What we can say is that we don't have them today. I think, I hope that we can be rigorous enough in how we construct diagnostic concepts that we only use the ones where we will eventually find a biomarker of some kind.
Whether that's a specific gene, a specific finding in brain functioning, such as a network effect. Whatever it is, I hope we can find something. I'm not optimistic. This gets us into more dangerous territory in terms of philosophy. You were saying?
I think going back to biomarkers, I think there's a chance we find rule-in biomarkers. There's a chance we don't get, well, I don't think we'll ever get rule-out biomarkers.
Well, when I talk about a biomarker, I'm at least wondering, I'm hoping for a platonic ideal. I'm hoping that we're not going to call it a biomarker unless it's both a rule-in and a rule-out.
Now, I think most of psychiatry operates as if we're on the cusp of figuring out the biomarkers, of figuring out the brain imaging, on figuring out the networking. We make pretend that we're playing this 5D chess of these high-level... There's the dorsolateral prefrontal cortex interacting with the blah, blah,
blah. Love to name those brain areas, right?
And we are operating... We're not even playing tic-tac-toe with our physical correlates.
I'm going to take offense to that. I think I'm a pretty good tic-tac-toe player. But yeah, everyone thinks that we're super biological. You trained for four years to learn tic-tac-toe?
Sorry, what's that? It took you four years of training to play tic-tac-toe?
Barely, barely. And yeah, I think you're barely able to play tic-tac-toe at the end of four years, which is by design, right? If you can emerge ready to go and as good as someone who's been practicing 40 years after four years, it's probably not a very difficult session.
But the thing is, the reason why you say that, the tic-tac-toe is the biological game. The game of psychiatry is not tic-tac-toe. But it's not the... We're not... The skills and things we learn that are important are not the biological components. I'm saying that the biological components is tic-tac-toe. I'm not saying the practice and... Important parts of psychiatry is tic-tac-toe.
It is tough. Basically, if I can draw out the model that I'm thinking of, what I think we do is that there is some very complicated underlying biological process. We hope that with some kind of technology in the future, we'll be able to detect it with at least one or two biological tests. most likely centering, based on what we know today, most likely centering around live analysis of functioning brain networks.
Good luck, guys. But what you're pointing out there, I think, anyway, is that without that technology, we definitely don't have that technology today established in the findings, then the art of eliciting the right information at the right time and putting it together in the right way to get to a treatment that will actually get somebody better and not worse, and that they will accept and carry through with and change with, that's the whole of treatment and psychiatry.
There's so much more beyond diagnosis. So what I say, when I was saying that you're barely competent at tic-tac-toe when you graduate, the tic-tac-toe I was referring to is the ability to basically formulate somebody to figure out what's the main problem I should be addressing. And then the rest of it, that's some really challenging stuff to get good at. I don't think you can ever master that.
Yeah. So you often put into words what I'm sloppily saying. And the big thing is that we may pretend that we're playing a biological game. And we're not. We're playing a psychosocial game. Because the way you described, like, you know, piecing together the information to give the best treatment or whatever, that is a, I think, understanding the psychological and social components outweigh the biological things to an astronomical degree.
And we pretend it's the opposite.
That's true. I think there's definitely a breed or a type or a personality of psychiatrist who wants to, wishes to, hopes to work primarily in the biological realm. I think that the medication revolution has really lent towards that process, and many people have been trained in that, have been stamped, graduated, and practiced that way. That being said, I would hope that I think it's responsible in psychiatry still to conceptualize well, each of us, what we think is more biological, what is more social, what is more psychological, not to say that I love the biopsychosocial approach because I think it's too simple.
And to communicate to people, I think this is something that's a little bit more from your genes or your biology. I think this is something that's a little bit more from your development. I think this is something that's a little bit more from your social environment. And I think this thing is some combination of those. Therefore, I think you should do X, Y, Z. I hope we're doing that as a field.
I don't know that we all are. On the whole bipolar and borderline crossover, it definitely annoys me personally, because I think it requires a misunderstanding of how to diagnose both things at the same time. I've written about this before online. What exactly are people seeing as the personality disorder that they're confusing the bipolar disorder? And let's use the DSM model. Let's use the outputs. What are you supposed to be identifying in borderline?
You're supposed to see efforts to avoid abandonment, unstable relationships, idealization, and devaluation across time, not between you So rather you and the patient, between the patient and doctor. Identity disturbance, recurrent suicidal behavior, self-harm, chronic feelings of emptiness, inappropriate intense anger, transient stress related to paranoid ideation, identity, sorry, impulsivity, and... Let's see. Affective instability. We get the point.
You're reading the card. But the problem is that's not what you're using. You're using an internal heuristic of what's occurring interpersonally.
Well, you shouldn't be doing that.
That's my whole point.
That's not how you should diagnose a personality disorder. I don't disagree.
You should not diagnose a personality disorder off of a countertransference. Of course not. Of course not. But I'm talking about what occurs.
Well, people need to be instructed on that. Really. Really, really. The internal process is extremely important in identifying how people function in their interpersonal element, basically their level of personality functioning. OK, but it doesn't give you a diagnosis. OK, it doesn't give you a diagnosis at all. It clues you in to what might be happening. And then you have to confirm your diagnosis by getting medical evidence.
And unless you have medical evidence for those things that I just mentioned occurring across the timeline of a person's life, at least reasonably, you shouldn't be making that diagnosis. You can suspect it. Put it in a rollout. But you shouldn't make that diagnosis.
Where are you saying this should occur, though? Are you saying this should occur in the emergency room? This should occur in an inpatient? This should occur in an outpatient?
This should occur anywhere that you're going to apply a diagnosis, okay, including the emergency room. And so therefore, in the emergency room, unless you have somehow found that information in the chart, because they've been there so many times and you know this patient, Or you have their medical records. They came in with some medical records. You shouldn't be making a borderline personality diagnosis.
You can highly suspect it. I'm upset that I'm arguing with a point that I entirely agree with, but I still am going to argue it. The issue, though, is that, you know, as I'm an ED physician sometimes. Yeah. that's great that I could sit down and figure out all those things if they're going on, but I don't have that time and I'll never have that time. And it's not, what you're saying is not doable with the workflow that is expected.
Well, if you'll entertain me, tell me what situation in terms of dispositioning a emergency, in psychiatry requires a personality diagnosis.
Oh, no, I'm going to lose. I'm going to lose the argument that I don't even agree in. Well, then let's not do that. Basically, I don't think it. OK, your your point. And I see if, you know, sometimes you want to know if what's occurring is it's helpful information. If you think they have, for example, a borderline personality disorder, if they're suicidal, how you're going to formulate the case.
Yes. If I find out the patient has been suicidal a thousand times and been in the emergency room a thousand times, I'm going to think very differently than if this person who's having an interpersonal conflict that's making them suicidal has never been in the emergency room.
That's right. Which is not at all a issue of which DSM diagnosis do they fit into, right? It's about their case history. And so really, when we disposition and we risk stratify cases like that, we're using case history. We don't need to opine on whether or not they have a personality disorder. Now,
this is interesting because then I do come across this thing where someone thinks it's very easy for me to make fun of other people. And that, Chris, is my own practice. So, of course, I never do this. It's just other people. oh, they have borderline personality disorder, they're not going to kill themselves. And it's not a protective thing. I would say it's confusing because in the general population, borderline personality disorder would be a risk factor.
In the emergency room, as a result of the fact that you see so many people that are borderline that don't do it, it feels like a protective factor. So the environment actually changes whether or not it's a risk or a protective factor.
I think people are operating that way. I think it's a little bit wrongheaded. It is a risk factor. It's just not as serious of a risk factor as perhaps severe, agitated psychosis with command auditory hallucinations to make suicide, right? It may not be as much of a risk factor as other things, but it's a risk factor. What we're identifying is that hospitalization is ultimately not necessarily beneficial for borderline personality.
It's really a treatment issue. rather than a risk issue. So I think that weighs people to say, well, the risk is lower when really we should be saying, well, the treatment may be better to do this or that. They're still at risk, right? They may not mean it in the same way. They may not act it in the same way. from an unconscious standpoint, but they still genuinely think and feel that they want to die a lot of the time.
Now, of course, there are people who will attempt suicides as a means of navigating interpersonal power dynamics. That's a slightly different set of people, right? Maybe a little more than slightly. And it gets complicated. But basically, my point being, we can recognize personality pathology, but we shouldn't get definitive in a short interview setting, unless you somehow in your emergency psych, it's a very slow day. You've got one patient and you're going to interview them for at least 30 minutes, which sounds short, but if you do it right, you can get something out of that.
You know, the other point I wanted to make was also that bipolar disorder is episodic. Usually the vast majority of the time it's episodic. So at least from the outpatient standpoint, I don't see how people are really confusing these things. That being said, I know they can worsen each other. The conditions.
When you say it's episodic, what do you mean? How can people confuse it?
Well, if we are identifying properly a manic depressive illness, a bipolar disorder, the changes in their functioning, their mood, their activity levels and sleep should be happening in episodes. You know, episodes, whether we're talking three days, three months episodes, It should be in episodes. There should be periods where they don't have that episode properly. It gets complicated when you have someone that has a persistent depressive disorder.
But all the same, there should still be some episodic fluctuation in their sleep and energy that is identifiable when both of you sit down together and take a look at their history together.
Now, a case I want to talk about, which you're going to get upset and say Goldwater Rule. is kanye west and i think he's a almost art like he is an incredible archetype of the problems i see with understanding personality and mood disorders and i'm actually reminded of one of a mentor described I'm going to butcher this. But the personality is the trunk of the tree. And wait, hold on.
The biological part is the trunk of the tree. And the person's personality are the roots that evolve around it. So if someone has a biological illness, their personality will adjust to it in a sense. And Kanye West is, at least how I'm not diagnosing him, just from my gossip-oriented perspective, I think he's someone who has a bipolar illness and a narcissistic – and struggles with narcissistic issues.
Yeah. And the mania brings out these narcissistic issues. And once the episode ends, he deals with the fallback. But because his personality structure is oriented in a way that he doesn't apologize, he makes sense of it as if he's not in an episodic state. He makes excuses, whatever.
Yeah. You know, by the way, we can get around Goldwater stuff by simply saying, Why don't we consider a hypothetical where there is a, you know, world famous rapper and musician with co-occurring narcissism and bipolar disorder? No, I'm kidding. That doesn't really excuse you. Everyone knows who you're talking about. But you bring up a good point. It's chicken and egg. I think it's very hard to say what's happening.
I will say that clinically, I feel like the incidence, the prevalence, whatever the correct biostatistical term is, the amount of patients that have personality pathology, at least traits or some dysfunction, even if they don't have full personality disorder, that have had childhood illnesses, they're higher. If you have some kind of a childhood illness, if you have something that interrupts your development, that's naturally going to make it more likely for you to have personality pathology.
So I think we have to drill back down to where does personality pathology come from? Well, there's some genetic illness, but majority of the problem in my mind, at least, is that there has not been the sufficient conditions throughout the development for whatever reason for people to develop their personalities, to mature, right? And any illness is going to keep you from maturing as well as you would have without it all the way into your later life.
You know, if you don't mature in your teenage years and your 20s, you're still time in your 30s and your 40s. And that's why we see that personality disorders go, quote unquote, into remission. Right. Often in the 40s or the 30s. But. Did you get that chance? And bipolar disorders, manic depressive illness, in my experience, even if you don't get the full blown syndrome until the 20s or 30s, it's present early on.
There is irritability. There is mood changes. There's problems of concentration. It's a big issue. So. I don't know where the trunk is. I don't know where the roots are, but they're definitely intertwined.
Now, you mentioned that in 30s, 40s, you kind of see personality disorders fade out. I've seen it occur quite often in men in 60s, 70s, 60s. Well, first, I'm curious if you agree with that. And second, what's the best way to formulate why that's occurring? Would it be
Yeah, that's an interesting question. It depends on what you're seeing. Tell me what you're seeing.
Sure. I'm seeing older men who previously struggled with anger and narcissistic problems. Once they become 60 to 70 ish, you see it burn out. You see that anger is no longer an issue. And a lot of their positive personality traits start to over. You see more of the positive stuff come out and more of the negative stuff decrease.
Oh, so you're talking about seeing an improvement, right?
Yeah.
Yeah, I mean, I think that's the same thing. That's the same thing that we're seeing here. It appears that people who seem to meet criteria for personality disorders early in their life can no longer meet criteria later in their life. You can see this in what I would refer to as the burnt-out antisocial or the tired antisocial. There are basically people who fundamentally have criminal and aggressive or psychopathic tendencies who get a little tired, right?
calm down a bit in their forties or fifties. I'm sure what you're referring to is maybe a higher SES version of that. Why is that happening? Why does anything like this happen? Why does anything go into remission without treatment? Well, For a personality, at least, I think it's because it's opportunity development and changes in the underlying biology. And the same way in rarer cases you can seem to have or develop a personality disorder or personality problem later in your life if, for example, dementia or a brain injury has sufficiently impaired other functions of your mind so that the personality pathology emerges.
So, yeah, people change over time when they get better. I expect that it's because they had the circumstances in their lives to let them mature and develop and to learn new strategies. And that's what we're targeting in psychotherapies. Right. That's what we're trying to accomplish. Get people to develop and change.
Yeah. And your point of the dementia and brain injuries, bringing out stuff that the way I formulate that. And it took me, I think, after residency to sort of think of it this way, is that we all are a mixture of positive personality traits and negative personality traits. And our personality is this weird interplay between these, you know, you can say different structures, different traits, whatever. And sometimes...
the negative personality traits can be compensated for by the positive things. So, you know, someone who's very kind can... Some aspects of that can, like, decrease their... Like, their anger doesn't come out because they're compensating for it with their... through some it doesn't even need to be like they're compensating for it and when you get the dementia or the brain injuries the ability to compensate is decreased so these negative things that were always there that were being compensated for
start to play it come out yes exactly yeah that's that's basically the same way i conceptualize it you have certain capacities you have certain abilities um in psychodynamic terms we would call them defenses and Right. That can mitigate or sublimate aspects of your animal instincts, if you will, or your childish instincts, your wants, your needs. If you lose those for any reason, whether that's just under transient stress or whether that's from a straight on brain injury or a dementing process, those issues will come out.
Right. And we see that that does happen. It doesn't happen to everyone, but it does happen.
I just want to check. Do you have to finish at 12 strict?
No, I was thinking we're doing one hour and a half, but we can finish whenever you want.
Wonderful. Let's keep going. I just want to make sure if you were done at 12. Now... Do you mind if I change the topic or did you have something?
No, no, I don't have anything.
There was something I wanted to go back to talk about because we were talking about bipolar. And I want to discuss a case that completely changed my understanding of bipolar. Now, this was a case that I had, I think, first year of residency. This person... was a problem on the units. I'm going to make up all the details and make up so that you can't possibly say who it was.
Um, you know, kid in his twenties, the thirties was combative. He was actually quiet. He had like this, like, uh, you know, like a thug like demeanor in that, like he was quiet. And if you ever try to talk to him, his, his he would go to violence like that and he was getting medicated constantly and he was like quiet and calculated and it everyone on the unit was like tell like we need to discharge this kid this kid is just a violent uh you know he's just violent there's no underlying problem I think I actually took over the case.
And at that point, no collateral had been collected and they didn't know any information about his background. And on the surface, as I mentioned, he wasn't talking much. He wasn't your typical picture of mania where you have this pressured speech, you have this flight of ideas, almost the opposite. He was essentially not talking that much and incredibly quick to violence. Everyone wanted to discharge him. And then I think like, you know, there was we're starting to discuss a plan to we finally got collateral and collateral is from mom and says, at baseline, he's a quiet kid who does well in school and has no violence.
And Eventually, I think it was like a three-week hospitalization. He was getting PRNs every... He was getting medicated every four hours. The mania broke, and we saw a totally different kid. who was apologetic for what he had done, felt like a ton of remorse. And I bring up this case because it completely changed my understanding of bipolar as, you know, the heuristic of this rapid speaking person who has highs of mania and lows of depression.
And it changed it to something as bipolar I now understand as two different, it's almost like two different moods, like two different self-states, two different ways of being.
Mind states, I would call it. Mind states. Even brain states to some extent, but mind is most accurate, I think.
And I might mess up the language because I haven't thought about this enough.
Well, we don't have any universal language as part of the difficulty of psychiatry. Come on.
And at baseline, it was very different than when he was in this different mind state. And it completely changed my view of what bipolar was.
Mm-hmm. Yeah, that's an interesting case. But that, again, emphasizes what I was kind of referring to earlier, right? Output behaviors are not underlying process. And everyone was going off of an output behavior there to ask, what is the underlying process? And maybe it was countertransference, maybe it was their pre-test conceptualization of existing mental disorders, but they said this is a dischargeable person. Which is funny because what was the actual output behavior?
This was somebody who wasn't talking much. This is someone who wasn't talking much who was repeatedly assaultive. Is that correct? This is what I do when I don't have collateral. Okay. I think I do have a little bit of privilege here because working in forensics requires you to reach some medically defensible conclusion about people who you see for up to 40 minutes. You know what I mean?
Not up to, but often just about 40 minutes or less, depending on the kind of practice setting. But when you don't have collateral, you cannot imagine that a person has presented because this is normal for them. It's always possible. I would say that that's a minority of the cases. You have to then start comparing them to an ordinary, regular person. And then you have to ask, what could be putting them in this state?
And you really shouldn't be putting personality as a number one thing, unless you have some very compelling evidence for that. Because that's just not normal behavior, right? And to me, by the way, we're not going to get into this, but that case makes me think about Catatonia. because that's actually more frequently seen in mood disorders than psychotic disorders. It sounds a little bit something like that. But yes, if you had, if not you, you did do this.
I agree, we shouldn't go down it,
but for the record, I think he was actually on high levels of benzos, but sorry.
Oh, there we go. Okay. And by the way, look at the, you need, what were the levels of benzos, by the way? Could you remember?
I want to say it was like Ativan 2 TID.
Yeah, that's nothing for some catatonia cases, by the way. Also, if he was younger, depending on how young we're talking about, even to adolescents, sometimes people need even higher doses. I've heard. I'm not an adolescent psychiatrist. Anyway, the point I'm making that I want to drive home, basically, is that you have to consider why is someone doing what they're doing in front of you that is different than what a normal person would do?
And you have to have a compelling reason to say why is that that they're doing it and in acute settings or settings where someone has been referred. Why now? Why, why is this now a different time in their life for them or for the people who think they need to be looked at? And there's usually good reasoning there and we can't ignore them.
So we have, let's say five minutes left. Do you have any final points? Do you have anything that you think is important to emphasize? Do you want to get on your soapbox?
Yeah. If you don't mind, this is a big topic for me. I think I am a self-professed bipolar, if not expert interest person, someone that's quite interested. Don't think of any disease process as simply what we understand it to be today. Consider that we conceptualize disease. We think about things as diseases because we want to be better. We want things to be better. We want to prevent things from getting worse.
That's really what the point of this is, any of it. So the point of a doctor, though it might feel bad if a doctor tells you you're sick or that if you have a disorder, the point of that is to get you better, to get you to change for the better, okay? And then for the clinicians, Don't restrict yourself to what is described in the DSM criteria alone.
Read through all of the DSM and then read even more. You need to understand for bipolar disorders, for example, the whole history or at least some of the history of manic depressive illness and what clinicians across the last century have understood this to be before we came to a limited DSM-5 model.
Yeah, you bring up a great point of the DSM today. Knowing the history, like sometimes I'll look back and if I watch an old movie or something and I'll hear a term that it's like, what the heck are they talking about? You know, like a schizophrenic term. You know, I can't think of it now. But when I look back in the DSM-2 or the DSM-3, sometimes I'll see terms that I actually think capture a patient better.
And it's like, how does that make sense? As you mentioned, what we have today is not perfect. It doesn't cover everything. There's going to be formulations in different areas outside of psychiatry, formulations from the past that actually capture patients better than the formulations we use today.
That's right. We should never forget that the DSM is not exactly a scientific document. We try to use science to inform it, but it's a product of professional consensus. It will change. It must change. And there are things about it that's probably worse than what it used to be and things that are better. But it's not fundamental reality. It's a reality we use in order to work towards treatment.
Perfect. I think a great example of that is the personality disorders, which the current personality disorder, the way it's structured, in my opinion, it's significantly it cuts out so much knowledge and is not the best way to formulate personality or personality disorders. And I know you have you really like the alternative model.
Oh, yeah.
Talk about it.
Well, the if you don't know this already, you should. It's in section, I believe, three of the DSM-5. There's an alternative model for personality disorders. It uses a dimensional approach rather than a categorical approach, and it centers the pathology around level of personality functioning impairments in self and others. Um, it, well, probably with that background noise, let's try something. Let's do it again. The alternative model centers to pathology of personality around, uh, personality functioning, which is about how we relate to ourselves and others.
Interpersonal functioning and self functioning. I think it's closer to what we really understand about how the personality works. And I believe it has more empirical basis.
Wonderful. Great closing points. Anything else that you think was.
Well, I mean, I want to emphasize we're not anti-psychiatry here, we're psychiatrists. Some of these points can be used and abused by anti-psychiatry zealots in order to use a broad brush to cancel out the validity of everything. in this particular area of medicine, don't listen to those people and don't let yourself think too black and white either integrate. Um, and, but there is no doubt in my mind that we were, we're going to get into more, uh, critical appraisal of the DSM and its characteristics as we go through different diagnoses.
You think we're gonna have more anti-psychiatry or pro-psychiatry people?
Ooh, uh, you know, Controversy invites audience membership.
We've got to be controversial.
Oh, boy. But I really don't like those anti-psychiatry people.
Say something inflammatory. We've got to get viewers.
ADHD is a social construct. That's quite inflammatory.
No, that's not... When you say something inflammatory, you have to say... With ADHD, people want to view things that say everyone's on stimulants. I agree it's inflammatory, but the views are...
Okay, well, people want everyone on stimulants because they think it's a biological illness, right? If you thought that ADHD was purely a social construct, which, by the way, I don't actually believe, then you wouldn't medicate. You'd change the society. But people think it's very biological. That's why they... Well, I don't think that's the only reason why, but that's why they think stimulants. They don't think, why don't we change the classroom structure?
Why don't we change the school structure? Why don't we change the parenting structure? dynamics. No, people don't talk about that. People say, where's my stimulant? I think that would be one of our... They don't say it that way, but they say something like it.
One of our next topics. Alright. So yeah, let's close it off. Thanks for talking to me. Hopefully we'll have...