Serious mental illness — schizophrenia, PTSD, major depressive disorder and bipolar disorder — impacts a large number of Americans. Yet despite the prevalence, treatment for serious mental illness (SMI) falls short of need.
Treatment is often unavailable, incomplete and un-coordinated with other health and social services which is sometimes based on faulty misdiagnosis by psychiatrists of someone they really don’t know that well and are not treating currently. It is also not really based on what the patient has to say or experienced in many cases.
This is seen as a critical error in judgment on the part of many psychiatrists and psychologists working in the field of mental and behavioral health who are often times never questioned or challenged in their respective determinations of SMI individuals during evaluations or re-evaluations.
In some cases these doctors and psychiatrists are impatient and don’t really listen to the patient therefore making misdiagnosis entirely possible, especially in those cases where they don’t know the patient or have only seen him or her once or twice before and only for the purposes of prescribing anti – psychotic drugs to that patient.
Often times you see “un-diagnosed or unspecified psychiatric mood disorders” or “unknown personality disorders or adjustment disorders” listed on evaluations and reevaluations of patients with SMI. Indicating that the psychiatrist involved didn’t really know what the underlying causes are of the mental illness for the patients involved.
Adequate time during evaluations should be allowed for assessment of patients with medically unexplained symptoms.
Although this can be difficult in the setting of a busy primary care clinic for medical outpatients, time spent engaging the patient and gaining a full history will pay dividends later.
Patients with severe and enduring medically unexplained symptoms will often have had negative experiences of medical care in the past (Reid, Ewan et al. 1991) (Deale and Wessely, 2001) and it is important that the patient “feels believed” whenever they are seen by a health care professional.
Therefore good communication skills are important for psychiatrists – who should never brow beat, interrupt or over talk patients trying to explain their conditions and psychiatric symptoms during psych evaluations.
Time and budgetary constraints however often times limit practicing psychiatrists from conducting more thorough diagnostic evaluations (source: Diagnosis of non-psychotic patients in community clinics http://ps.psychiatryonline.org/article.aspx?articleID=180557).
It has been found that most clinicians evaluate patients using an unstructured, open-ended and sometimes biased approach toward their clients, with limited training in evidence-based assessment methods, and that inaccurate diagnosis may be quite common in routine practice (source:http://ajp.psychiatryonline.org/article.aspx?articleID=174060).
In 2013, psychiatrist Allen Frances wrote a paper entitled “The New Crisis of Confidence in Psychiatric Diagnosis”, which said that “psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests”. Frances was also concerned about “unpredictable overdiagnosis” (source: The New Crisis in Confidence in Psychiatric Diagnosishttp://annals.org/article.aspx?articleid=1688399).
One SMI patient said it best “The doctor asked a few questions and constantly interrupted me as I tried to elaborate and explain my condition in depth.”
Recently I was also confronted by the same thing with a psychiatrist who is highly respected at my clinic during a standard SMI reevaluation who insisted I did not have PTSD after not allowing me to fully explain why I felt I had that underling diagnosis.
His response was “you don’t have PTSD.” When in fact he actually had no idea if I had it or not?
Later the doctor became frustrated and frequently interrupted me (as the patient) and cut me short during conversations while I tried to explain what was going on in my case. Like he knew best?
Finally he dismissed my explanation of PTSD as a possibility altogether and the session abruptly ended after less than 40 minutes with him. During which time he only scribbled down a few notes on a single white sheet of paper.Doctor knows best? Maybe not all the time!
In my case I am haunted by reoccurring nightmares (or night terrors) of my experiences in the military, which included a flash -bang grenade simulator going off less than 5 feet from my head during a training exercise, and having to be force-ably taken down by drill sergeant’s in basic training during CS gas exposure training where we were “required to remove our masks and state our name and service number while breathing toxic gas – before being allowed to run outside to breath oxygen.
In my case I “flipped out” and went berserk!
I was later treated at an Army hospital for acute CS gas poisoning ans swelling of my face and head when I was hit repeatedly by the drill sergeants struggling to get me under control. Of course I don’t fault them in this at all and probably would have done the same thing if I was in their shoes. I did resent however that they had the luxury of wearing their masks at the time they were shouting commands at me when I didn’t.
I was also “knocked out” cold one time during combat training at Infantry School at Ft. Benning, Ga – involving a live fragmentation grenade when I hesitated throwing the grenade with pin pulled over a concrete barrier because I was frozen in fear. Of course I don’t fault the sergeants in that case either because they probably saved my life (as well their own in that instance. But the fear lives on within me to this day – some two decades later.
I was also punished selectively once when I fell behind on a forced 10 mile march – and was made to stand before my entire platoon by the drill instructor as “they” were punished for my failing to keep up with the formation during the march.
That night I received a brutal beating in the form of a “blanket party”- where members threw a blanket over my head while I slept and held it down while dozens of guys (many acting under peer pressure) took turns beating me with their clenched fists and feet. Of course I did not dare to report that incident lest I get another beat down later on – needless to say I never failed to fall behind in a forced march again, despite my feet bleeding so bad from calluses and rubbing wounds that the blood pooled in my boots and squished every time I took another step. A condition which I also required medical care to treat later on.
During bayonet training – I became fearful and suffered a pretty severe “panic attack” after hours of repeated bayonet drills where we had to respond to certain rhythmic cadences: “What is the spirit of the spirit of the bayonet?” We would then shout out: “To kill”. What are the two types of people on the battlefield? – we would scream back: “They quick and the dead.” What are you! – “The quick.” What are they – the dead and so on and so forth – for hours at a time as we preformed bayonet moves taught to us, such as parries and trusts ….
That night and subsequent nights there after I began suffering what can only be described as night terrors of visions and dreams of being stabbed through by a bayonet by enemy soldiers on the battlefield.
I also found out rather quickly during Jump School at Ft. Benning, Ga that I was absolutely terrified of heights and tried unsuccessfully to terminate jump training on several occasions by trying to tell “Black hats” instructors I wanted to stop and was instead told to “suck it up- soldier”, given punitive punishments of push ups, yelled at, ridiculed, called names like a “panty waist” and given extra duty (in the form of corrective training scrubbing toilets) and most frightening of all – I was place first in a chalk position to stand at the door of the C-130 aircraft so I wouldn’t slow up the other soldiers deploying from the aircraft over the drop zone.
When I hesitated for a few seconds one time after the green light came on and the command was given to “go, go, go” – I was forcibly shoved out the door screaming with a foot in my ass.
Another time I was dropped over trees near the edge of a open field and was almost impaled by tree branches cracking and breaking as I made my decent . I also spent hours hanging in the trees impossibly tangled up in my risers and parachute before I was eventually found and rescued.
So I took real offense by the psychiatrist in this case ( a man who never served himself in the military himself) telling me I did not suffer PTSD because I didn’t see or experience real combat.
These and other example abound of psychiatrists failing to listen or understand SMI patients they diagnose or evaluate are more frequent than you can imagine.
The situation portends to a much deeper problem within the already overburdened psychiatric and mental health community, especially where it concerns the diagnosis of PTSD.