written by reader Introducing: Psychiatry Simplified

A NEW COLUMN BY DR. PETER TILTON, PSYCHIATRIST

By ptilton45, January 23, 2015

[ed. note: This is an introductory piece from longtime reader Peter Tilton, who has proposed writing a regular column for Stock Gumshoe readers about psychiatry. Not an investing topic (though the behavior of many of us in the markets may well be something that’s in need of a diagnosis), but we thought you might find it interesting. Please share any feedback either in the comments below or on our contact page — we’d like to know if you’re interested in reading more of Peter’s work. Thanks!]

In my first article of Psychiatry Simplified, I’d like to start with what modern day psychiatry is about. Simple. Diagnosing and treating mental illness with medication. But before delving further, I’d like to tell you a bit about my medical career. I have been a psychiatrist for 20 years. Before that I worked in primary care in many varied capacitiesfree clinics in the 1970’s, emergency rooms, private practice and a holistic medical practice. As a psychiatrist I have worked in private practice, alone and in a large private multi-specialty clinic. I have done forensic work and treated workers’ compensation patients. But for most of my career I have worked in the public sector, inpatient and outpatient. For ten years I worked in a county outpatient children’s clinic and spent some time at a county juvenile hall and boys’ camp. I have treated adults in a small acute inpatient hospital and have worked in several types of outpatient clinics as well as a crisis outpatient center. If I have a specialty, it is treating severe, chronic and persistent mentally ill patients with psychotic disorders (schizophrenia, etc.) and mood disorders (bipolar disorder, etc.) with medication. That is not to say that I don’t use psychotherapy in various forms with my patients. While in private practice I treated people with short term (brief, paradoxical, hypnotherapy, etc.) and long term psychoanalytical psychotherapy based on Heinz Kohut’s self psychology model.

In the public sector my main role, besides taking part in team meetings and decisions, is diagnosing and treating my patients with medication. I am very conservative, meaning I try to use the least amount of medications needed. While polypharmacy (using more than one medication) is more the rule these days, I try to limit this approach. On the other hand, I am also very aggressive in that I will do what it takes once I start, meaning I will continue to raise the dose based on symptom relief versus emerging side effectsa risk/benefit approach. I am not averse to adding medications, but unlike many of my colleagues, I also take away medications or lower a dose when warranted. I must admit that there have been times when I have lowered a dose or stopped a medication and discovered my mistake by the reemerging of symptoms.

I have also had the privilege of working as a psychiatrist in New Zealand, both north and south islands.

Psychiatry is different than all other fields of medicine in that we have no lab tests, scans, x-rays or procedures that accurately help us with a diagnosis. No fracture on an x-ray, tumor on a scan, positive urine culture and sensitivity to guide us in our treatments. There are, in the domain of psychology, tests like the MMPI, etc., which can be used for diagnosis, but I believe a thorough history in a one-to-one situation to be the most accurate way to obtain a diagnosis and overview of the person seeking treatment. Add that to input of any family members or friends and the picture becomes more accurate. The information gathered goes into a sort of thinkolator (after all, this is a Gumshoe website) and out comes a working diagnosis.

In psychiatry this thinkolator is most often the DSM-V (Diagnostic and Statistical Manual), the bible of psychiatry for much of the worldalthough many use the ICD 10 (International Classification of Diseases) and there is good correlation between these two sources.

While the DSM offers brilliant descriptions of mental disorders and lists the criteria for making a diagnosis, there are problems. There is not universal agreement among the members of each work group and politics (surprised?) plays a part in what gets included and what does not. What is missing is the possible origin or cause of the current symptoms or disorder. “Why now” doesn’t matter. It is the constellation of symptoms that does. Another way of putting it: does the patient have the requisite number of symptoms to be given a diagnosis, let’s say having met 5 criteria out of a list of 9 needed to make the diagnosis of major depression? If a person fails to meet the criteria, the DSM offers an NOS diagnosis. NOS means not otherwise specified. Meaning if it walks like a duck, looks like a duck, but may not quack like a duck, it is still a duck. Sort of. It is a Duck NOS. This can be helpful in what is known as a spectrum disorder. There are some symptoms suggestive of the disorder but not the full blown picture. This is very common in today’s literature regarding bipolar disorder and autistic disorders.

So, getting back to making a diagnosis and deciding upon treatment, a well-trained clinician will ask, “Why now?” And that should include why are you now coming in for treatment, and what if anything has happened recently in your life to cause (whatever the symptoms are). Using the example of depressive symptoms, what led to the symptoms should lead to treatment considerations. If I’m presented with a patient with an adjustment disorder with depressed mood, I need to understand the source of the stressor—this is paramount to deciding on treatment, and most often some type of psychotherapy is tantamount to successful treatment. Antidepressant medication may or may not be needed, and a short term prescription for anxiety or insomnia may be needed, because reduction of symptoms is a major goal and sleep a must, as is freedom from anxiety.

I’ll go into depression and all other mental disorders in later articles. Depression was only used here to show the complexities of psychiatry.

Now, unlike the great Dr. KSS, who imparts his MD and PhD knowledge to enlighten us about investment opportunities, I will not. Mainly because, if I did… well it would be like the blind leading those who can see. I am no expert in giving investment advice.

However, I will disclose that I have been a paid speaker and consultant for Pfizer, Novartis and Forest, but have only presented talks about medications I have used and felt were beneficial and among the best in their class. In future, I will only refer to medications by their generic names. When appropriate I will mention any company that is part of my portfolio.

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Also, I cannot give the kind of medical guidance, often so brilliantly offered by Dr. KSS. One, because I cannot be sure that whomever you asking about has been diagnosed accurately. Basically, I trust no one but myself. That is not to say the diagnosis is not correctI just have no way to corroborate it. Two, prescribing for mental disorders is not (sometimes) as simple as other medical conditions and the results may not be seen for weeks. I will be happy to answer some general questions about treatment, symptoms, medications, side effects, etc. but I expect you to do your own research first. Google or Bing or Yahoo will be happy to help you with general questions. And finally, absent the intimate doctor-patient dyad (therapeutic, placebo, luck, etc.) I can be of little personal help.

In these columns I will attempt to simplify what is known and probably ignore what is not practical for today’s treatment options. While there may be tests available (like assessing serotonin transporter genomes) they are not in everyday use and as yet don’t prove who will or will not respond to antidepressants that presumably work on the serotonin system. When it comes to medications, I can tell you now, no matter what you read or think, no one actually knows how and why most psychotropic medications work. Yes, it is known that medications work on specific receptor site as agonists, antagonists, etc., but that is not necessarily the whole story. I will talk less about the arcane science, since I am not a researcher, but will discuss what I think to be relevant. In this way I will attempt to offer you Psychiatry Simplified.


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dan62
5 years ago

What it is a moneky?

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Alan Harris
Alan Harris
5 years ago
Reply to  dan62

Good of you to chimp in daniel.

Alan Harris
Alan Harris
5 years ago

Travis re your #39 reply: you will be glad to hear that this is my last comment on the matter. As Lulu says, SG is YOUR baby. Unless YOU aim to broaden SG’s scope beyond just tease bustin’ and profit chasing, publishing this column as a main article was probably a mistake. If (as accepted) you were just trying to gauge peoples opinion, perhaps the better route would have been to publish it as an Irregs Discussion and simply announce the first installment widely. Thereafter, you could have judged by the replies/subscriptions whether this was worth serial notification and an upgrade to main site. I mean, the issue really is all about the intrusion of a ‘general notification’, not publication, coz anyone can start a discussion even on sex, lies and video tape. But by taking a Simon Cowell approach and abandoning the decision to the public to vote, I feel you have done a great disservice to Peter Tilton, placing a distinguished author in the stockade to dodge rotten eggs, without any publisher support. As we all know, KSS is particularly sensitive to disrespectful posts. Had he got even 1% of these ad hominem replies to his first article, there would never have been a second KSS column. That would have been a great loss to SG and all the many many newly subscribing Irregs.
Peter: As a feeling human, please accept my apologies for all you have been subjected to by way of this ‘experiment’. At the very least, if some good is to come of it, you may have saved others from similar abuse. Please continue….many here recognise that theres more to life than making a quick buck, and we are all ears.

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Travis Johnson, Stock Gumshoe
Reply to  Alan Harris

I wouldn’t say Dr. Tilton was “subjected” to anything untoward. If the feedback was offensive to him in some way, then obviously he can speak for himself. He proposed a column, I ran it up the flagpole, and I’ll follow up with him after we’ve assessed the reaction. Thanks again.

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Alan Harris
Alan Harris
5 years ago

So, was the main site the right place for this article?. You da man….you da publisher. Its your flagpole.

Travis Johnson, Stock Gumshoe
Reply to  Alan Harris

Only one way to find out 🙂

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hipockets
5 years ago
Reply to  Alan Harris

Well stated, Alan. I agree with you on all counts.

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wiseword
wiseword
5 years ago

Mira Amiras got it right — self promotion. As the fellow said about hitting on women, “Nine times out of ten I get my face slapped, but the tenth time — wow!” Aim the pitch at a sufficient number of irrelevant sites and at least one will be sure to connect. Maybe Groupon?

Don Barrett
Don Barrett
5 years ago

Travis,

Your comment seems to imply that if you go with the column, it will be emailed to everyone. Kindly help us understand; wouldn’t this column be like any on the Irregulars’ site — it must be subscribed to in order to receive emails of posts?
If people have the choice, then why not have it. It is additive and in no way detracts from other topics which may be of interest to others. Alan says it right, it’s a bonus; how wonderful.

Thanks, and a special thanks to Peter, for wanting to share what he knows and loves, as do we all!!!

Also, have to say, Lulu, your comments are charming and make me smile.

Don

jomcintyre
jomcintyre
5 years ago

I like this idea for a new column. As the comments above show, there is a huge scope of material to cover. For me, I was hoping to hear about how we can think about how we think about investing. How can I analyze why I hesitate to sell a stock, but the only hindrance to buying is lack of money? Can I psychoanalyze myself to my benefit and learn to invest in a less emotional or un-mindful way?
So, have at it, Dr. T! I look forward to your next column!

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Mike Bee
Mike Bee
5 years ago

Dr Tilton is doing us all a GREAT FAVOR.
By discussing, in simple terms, vital things that impact each and every one of us Dr Tilton is helping us gain a clearer idea of what influences our actions and behaviors.

searchingwayne
searchingwayne
5 years ago

Thanks for this and, I hope, many more to come. Wayne

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jonomalley
5 years ago

I for one have no interest, Travis. I agree with whoever that said would prefer sticking to investing. I’m guessing there are a plethora of sites dedicated to psychiatry. (If anyone is wondering, the answer is yes: I DO know what “un plethora” means.)

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mary
mary
5 years ago

Dr Tilton, How do I find a trustworthy psychiatrist in Chattanooga TN (or surrounding area). My daughter sees one now, but I am worried about the meds she has been prescribed and would like a 2nd opinion. (have e-mailed Dr Kss about this; he kindly responded and also does not think abilify should be the first choice—the md also added remeron and my daughter has gained 40 lbs in less than a year. She has anxiety, depression, and is suicidal–also on meds for narcolepsy–she is 26).

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mary