One Patient, Two Perspectives

It can be difficult to put into words why I have found my psychiatric training and how standard psychiatry is practiced today lacking. On one end, we have smart, compassionate, well-meaning, highly trained clinicians and on the other end, we have motivated patients wanting help. Both of whom want the same thing: to help the patient get better and feel better. We are training more psychiatrists and more patients are being seen and treated with psychiatric medications, and still my practice is full of those who have seen a psychiatrist, started on medications but are no better.

There are many reasons why this is, one is the increased recognition of mental illness. Another is how, experiences like loneliness, polarization and addiction are becoming more of the norm living in Western societies today, and they erode the natural resilience of the mind.

Here I want to focus on another reason why mental illness persists despite standard of care being provided, and that is the simplification and medicalization of mental illness such that we have lost sight of the holistic care that is necessary in getting people sustainably better.

As an example, below are two clinical impressions of the same patient, a fictional character named Beatrice. This is loosely based off a real example of a patient I assessed 18 months after she had been seen by another psychiatrist.

The first clinical impression represents how most psychiatrists practice and provide care. It is what we are trained to offer at the end of a 60-90 minutes meeting with a patient.

The second impression is simply another way of conceptualizing the patient. Few psychiatrists see patients this way anymore, or even know what to do with the patient when given a clinical impression like the second example.

I will let you, the reader, come to your own conclusions, thoughts and feelings about each clinical impression. It goes without saying that there are important implications for how mental health is understood, and how mental health care is resourced and delivered depending on which approach is taken by the clinician, and on a larger scale, by health care policy makers.

Clinical Impression #1 - Standard psychiatric care:

Beatrice is a 56 year old woman who was referred to our clinic for treatment recommendations for his depressive and anxiety symptoms.
She reported that the identified stressors were a change in her fibromyalgia medications and her employment related both occurring in July 2020. She denies any prior depressive (and also clear anxiety) symptomatology and reports ongoing symptoms since.
According to the presentation, she would fulfill the criteria of an adjustment disorder but most patients return to their previous level of function within 3 months of the stressor. Furthermore, Beatrice's current presentation fulfills the criteria for both panic disorder and major depressive episode - mild to moderate, chronic disorders that might have evolved as initially comorbid to adjustment disorder.
She presented today with excessive anxiety and worry, constant, daily with difficulty controlling the worry. She described restlessness, feeling keyed up, being easily fatigued, difficulty concentrating, irritability, muscle tension and unsatisfying sleep. She presented with uncontrolled panic attacks despite taking her psychiatric medications regularly. She reported that the anxiety symptoms are the most disturbing. Her social, occupational, cognitive and domestic life functioning is described as impaired.

Her expectation from the current assessment were recommendations regarding her current medication regimen and other optional pharmacological recommendations. As this is a one-time consult, I will make some recommendations for her to follow-up with through her family physician.

Clinical impression #2:

Beatrice is a 56 year old woman who has a complex history. She has a chronic pain syndrome but also has a history of excessive alcohol use. She has struggled with her weight life-long and has attached much of her self-worth to this, and though she denies any history of trauma I wonder if she is under-reporting as she has a poor memory of her upbringing but remembers growing up in an emotionally unsafe home where she was in foster care and experienced her foster parents as hypercritical of her, insensitive and self-absorbed. She now reports being married to a narcissist, but her laissez-faire demeanor when describing this relationship makes me think she is used to being treated a certain way and detaching herself from any difficult emotions that arise. Other evidence that things in her life are more chaotic than she may realize, is that she is heavily in debt. She also refused to discuss some very difficult experiences/memories with me today.
In addition, consistent throughout is a pattern of self-destructive, addictive coping mechanisms: binge-eating, substance use, and over-spending. Because the psychological issues underlying her poor coping are not in her full awareness and have not been addressed, I am not surprised that she continues to struggle in her relationship to her body and with food. She is looking for medical weight-loss options, but I believe they will not be very helpful if her psychological difficulties are not addressed first.
Given the above, it is very difficult to know what is contributing to her symptoms psychiatrically. She describes labile moods and anxiety. There is a possibility that she may have a bipolar spectrum illness given her history and her poor response to antidepressants so far.
Though she denies symptoms subjectively of a personality disorder, her presentation today and attachment history as well as her impulsivity and poor sense of self are suggestive of a personality disorder and/or complex Post Traumatic Stress Disorder. Her alcohol use will exacerbate her symptoms and I believe she struggles with a substance use disorder.
At certain moments in the assessment, she had a lot of difficulty verbalizing her experience and feelings. I do not think she has had support with this in the past. I do not think she has been believed or emotionally validated. It would likely be very helpful for her going forward to access this through therapy, to better understand what is going on for her psychologically and that this will likely improve her symptoms more sustainably than a medication.

Because she is wanting a medication to support her recovery, I have offered to start her on a mood stabilizer that targets bipolar depression to see if this can help her feel more stable and in control of her mood as she embarks on psychotherapy. I will continue to follow for diagnostic clarification and treatment optimization.