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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chibana
Irregular
👍1417
chibana

Peter, Thanks for sharing your great insight. Very informative. Mental illness can be so devastating to friends, family and co-workers of the patient as well. I am very grateful for those that serve in the critical field of psychiatry. On another note in the Army we worked very hard to try and determine early signs of suicide and try to get our Soldiers to professional help ASAP. Often signs of depression were early indicators. Military gets a bad rap in my view when suicides are reported since we have such a large young average population placed often in incredibly stressful… Read More »

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archives2001
Irregular
👍89
archives2001

Peter and Travis: Thank you both so much for this needed addition to Stock Gumshoe! Psychiatry/Psychology and health go hand in hand with economics and are an essential segment. And when I state health, I especially mean nutrition, body, mind, and spirit. Now Peter, taking this a step further, I’ve been doing a lot of reading on the subject of probiotics and prebiotics which science has known little about until a few years ago when they suddenly realized just how important a part that microbes play in health and disease. (Especially mental health.) Here is a clip that I would… Read More »

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Michael Isaacs
Guest
Michael Isaacs

I think we may be straying too far from our core interests here, Lets keep the focus of Stock Gumshoe on the investing universe and leave medical issues such as Psychiatry to other media.

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archives2001
Irregular
👍89
archives2001

Sorry, Mike…
I emphatically disagree with you.
Medical AND HEALTH issues should be discussed here most definitely!
HEALTH is an ESSENTIAL footing of Economics!!!!

chrisgoodwin
Member
👍0
chrisgoodwin

Dear David, I appreciate your emphasis, but the degreee of your conviction is not an argument, You say “HEALTH is an ESSENTIAL footing of Economics!!!!” – but itis not obviouswhat you mean by this. What is a “footing” ? Is it a “foundation” ? And if so, in what way, what sense ? Health is essential for life: failing health is indicative of life risk, and so health underpins economics, art, work, philosophy, religion, crime, war, sin, and rice crispies. (Disclosure: I do not own shares in any cereal company.) A long term patient in a Hospital or nursing home… Read More »

archives2001
Irregular
👍89
archives2001

Thnx Chris, good to hear from you.
Sorry for this tardy response.
To get right to your point, This is what I mean by ‘footing’.
Here’s an excerpt from Wikipedia:
“The ultimate goal of economics is to improve the living conditions
of people in their everyday life.”
And here is what Google states:
ec·o·nom·ics
ˌekəˈnämiks,ˌēkəˈnämiks/
noun
noun: economics; plural noun: economics
1. The branch of knowledge concerned with the production, consumption, and transfer of wealth.

Alan Harris
Guest
Alan Harris

Michael: I disagree. How can you possibly invest successfully in anything unless you have some understanding. It’s very simple…..if you only want to read about investing and dont find this sort of article helpful, don’t subscribe to the thread. But leave those who are interested to subscribe. We are all given that choice.

Jim Leavenworth
Guest
Jim Leavenworth

Alan, I second that emotion:-)

Buell Carruthers
Guest
Buell Carruthers

I agree with Michael. This is NOT the place for Psychology. Stick to investing and the markets. There are lots of other places on the internet for Psychology.
Buzz

poppajohn
Irregular
👍27

Alan, I agree. Dr. Tilton should have been around for the psychology of our heated but eventually friendly discussion.

hipockets
Irregular
👍1221

Michael Isaacs – If you don’t want to read columns that are not related to investing, you don’t have to and don’t subscribe to the emailed notifications. Personally, I’m looking forward to more articles from Dr. Tilton.

Now, please excuse me while I reply to the voice inside me that made me say that. 🙂

mary
Irregular
👍792
mary

Michael, I was thrilled to find this column and was thinking how lucky I am to be a member of SG where different subjects are discussed by intelligent people. I am sorry you are not as excited by the addition as I. Those who are not interested in Dr. Tilton’s column can just not read it. Doc Gumshoe also has interesting medical columns I enjoy which do not include stocks. I feel the more about health I understand, the better I will understand the biotech stocks we do discuss….see ya on Dr Kss’s and Travis’s threads!

LostOkie
Irregular
👍306
LostOkie

Why is everyone coming down on Michael? Travis specifically asked for our opinion, did he not? And isn’t that just what Michael did? Doesn’t seem right to be ragging on him just because his opinion is not the same as yours.

As for myself, I’m entirely neutral on having these articles. Having them here is fine with me but I doubt I’ll read many of them.

Just my 2 cents
LostOkie

Alan Harris
Guest
Alan Harris

Well done Peter. I am totally ignorant about this subject, so welcome a light into its murky corners. Being a practical person, somehow regular medicine is far easier to understand……youve got some bug (or whatever) so the doc prescribes a pill that kills the bug. Once the bug is dead, its ‘Have a nice life….Next patient please!’. But Im just not sure whether mental illnesses are ever ‘cured’ or just alleviated by a good chat to get it off your chest and the prescription of some stabilising uppers for those who are down and downers to calm those who are… Read More »

Jonothon Gross
Guest

Peter, I look forward to your installments. It is quite a difficult task you are undertaking, simplifying psychiatry. Alan, if I may venture thoughts about your question above (I am also a psychiatrist, and for many decades, a friend of Peter). The answer is, not unlike many aspects of life, not simple. As you mentioned, a bacterial infection can often be called cured, but as you seem to anticipate a troubling emotional malady is rarely amenable to such an all or none evaluation. That does not condemn one to either suffer without relief OR take pills for the duration. It… Read More »

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Rusty Brown
Guest
Rusty Brown

Dr. Karen Horney would disagree.
Her “Self-Analysis” (1942! Before some of us were even born!) details how an individual, often with support of a friend or mentor, can approach and even resolve many of the neurotic issues in one’s life, and her writing style alone makes it worth the read. Crystal clear narrative on every page and brilliant insight into the issues from the past that can plague us until they are resolved. One of a series of such discussions, “Our Inner Conflicts” being another. Fascinating stuff, IMHO and beautifully written.
Don’t get me started.

archives2001
Irregular
👍89
archives2001

I totally agree Rusty…
A giant in this complex movement.
The orthomolecular field is another.
It demonstrates the direct relationship between nutrition
and mental health.
Drs Linus Pauling, Carl Pfeiffer, & Abram Hoffer were founders.

Ter Star
Guest
Ter Star

I happen to have been a Psych major in my college days and I would support the inclusion of Dr. Tilton’s offerrings among your offerings. I firmly believe that there is far more mental illness throughout our population than the average person might suspect. The population is under served in this arena because “it” is not identified and/or seen as a “treatable” illness until there is a bona fide diagnosis. The inclusion of his articles might allow more people to become familiar with the under lying symptoms and precursors of mental illness…as well as some idea of potential treatment and/or… Read More »

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William McCall
Guest
William McCall

I worked in the Social Services field for over forty years and in retirement found my second career as a Psychology instructor at one of our local Community Colleges. Most of the classes I teach are introductory courses meaning a great many students have no formal introduction to the subject and sadly, some have incorrect, pre conceived notions about what psychology and the related fields, psychiatry, social work, etc, consist of. They are amazed for example, to learn about the scientific method of research in psychology, assuming that it was more of a, “let’s throw something against the wall and… Read More »

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Rusty Brown
Guest
Rusty Brown

But “pick and choose” all too often means “wade through pages of stuff that has no bearing on what you came here for”.

hipockets
Irregular
👍1221

Rusty, what has no bearing for one might be important to another.

Alan Harris
Guest
Alan Harris

If you dont subscribe, you wont need to wade. Poor you if you are ‘forced’ to read Travis’ opener ….did you ever ‘happen’ across an unexpected topic that opened up a whole new world of interest?

jyoung0071
Irregular
👍577
jyoung0071

Thank you Peter for an incisive opening piece. Your exposition is both very learned and yet clear-cut and pratical. I will look forward to learning a great deal from what you offer on this subject. A wise person once said to me: “If you know a family that is not affected by mental illness, then you do not know that family well enough”. Thanks again.

Rusty Brown
Guest
Rusty Brown

1. I’m with those who think that Stockgumshoe should stick to its core interest – tracking down and discussing those promotions we get in our email come-ons; 2. Any consideration of psychiatric disorders should always start with an examination of what the patient is consuming and not consuming. Nutrition really does play a role in brain function. Is this individual getting enough B vitamins? Enough dietary lithium? “…Several research studies have confirmed that link between high levels of lithium in tap water and low incidences of suicides, admissions to mental hospitals, murders and rapes…” etc. etc. 3. As for the… Read More »

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hipockets
Irregular
👍1221

Rusty, I don’t know how to interpret your paragraph 3 above. Are you saying that being gay is a psychiatric condition, or that the Board should not have taken 12 years to follow through on the removal?