Diagnosing, Treating, and Differentiating Core Psychiatric Conditions with Nassir Ghaemi

0:02 [Music] today we delve into the complicated world of psychiatric diagnosis and their impact on treatment welcome everyone to this episode of the carlat Psychotherapy podcast I'm Mark Ruffalo editor and chief of the carlat Psychotherapy report and I've got with me today uh a guest Dr nir gami of uh tus Medical Center and Harvard Medical School Dr gami is director of the psychopharmacology consultation clinic at toughs leading expert in bipolar illness and lithium therapy and has written extensively on the philosophy of Psychiatry today I I've got some questions for him about

0:49 Psychotherapy about the diagnostic hierarchy in Psychiatry and a few other topics so welcome to the podcast Dr gami it's great to talk with you today thanks Mark nice to be with you yes so my first question for you is you have have argued in some of your writings that the of repeated claim that medication plus Psychotherapy is better than either alone is untrue and that it should not be generally accepted can you tell us why you you make this point well my claim is not that it's untrue inherently my claim is that it's not true inherently the The View that that's obviously true is either unproven or demonstrably false

1:38 it could be though that in some cases the combination is helpful and that's something that needs to be proven and has been shown in some things for instance it depends on what condition you're treating let's just take a simple example like acute Mania there's no research that shows that adding Psychotherapy to antis psychotics for acute Mania is more effective than anti psychotics alone so that one example is enough to disprove the general thesis even acute depression depending on what kind of depression you're looking at acute bipolar depression antidepressants don't work at all so adding Psychotherapy to antidepressants doesn't make that any better neither of them are proven effective acute unipolar depression which is a place where people often talk about this there's some evidence that the combination can be

2:24 more effective than anti-depressants alone in some studies but then not in other studies and if you dig into that research my general summary of it would be that most people don't make the summary I think this is a correct interpretation that is underappreciated when you look at very severe depressive episodes the combination of CBT cogn therapy plus antidepressants has been shown to be more effective than anpress alone but when you look at mild depressive episodes it has not been shown to be more effective interestingly though in mild depressive episodes CBT is as effective as any pressence so it's not that you need to take both it's that you could take either one but adding both doesn't add anything whereas in severe depression antidepressants are more

3:10 effective than CBT alone but when you combine both they might be more effective so it really depends on what what you're talking about what's the syndrome you're treating what does the research show that's my view it's not that generically more is better which is if we can get into it if you like it's really a reflection of a deeper philosophical belief among many people in psychiatry in the so-called biopsychosocial model and the view that more is better and eclectically people combine and add interventions on a general theory like that but that theory itself is questionable as I said I think it's better to base those judgments on actual research and evidence rather than belief systems yeah so looking at the at

3:57 the illness or the condition and the the research specific to the the identified problem rather than making a broad claim right because if sometimes people can just be treated with one treatment why give them two you know maybe they don't even need medication maybe Psychotherapy alone would be enough so there's no reason to inherently overtreat people both for costs and also for harms side effects and stuff which really leads me to the second question that I have you mentioned eclecticism and I was recently taking another read of your text concepts of Psychiatry and uh which I uh recommend to everyone listening you've criticized eclecticism in Psychiatry and argue that

4:43 it can lead to undisciplined and unscientific practice in some cases can you share you know your general thoughts on this topic and and what this means for specifically for Psychotherapy as a treatment and as a discip one right I think it leads to Anarchy and I think that's the way Psychiatry is now we live in an anarchy there's no ruler there's no guidance there's no laws everybody just does whatever they want to do people will defend that and say well that's great people are free to treat however they want to it may be great for the clinician who just has a belief system and wants to get pay for it and pay his mortgage but it's not great for the patient who basically can be treated by different people in so

5:29 many different way with no Rhyme or Reason to it that's why in a recent Gallup poll random selection of Americans gave mental health clinicians a d or an f grade in 60% of cases only 1% gave us an a 90% gave us a c or less the biggest groups being dnf we may like it but we are our patients don't like it and ultimately that's the important thing now what I see so often in the Psychotherapy world is that eclecticism becomes a justification for throw anything at the patient and see if it sticks it's just a very unprincipled stance and unsupported by you know the research literature which looks obviously at specific treatments for specific problems right well the whole concept of eclecticism is unscientific

6:15 or anti-scientific so it wouldn't be something that you would look to research for it's just a it's a theory it's an ideology and it really grows out of if I can put this briefly the larger context in in our modern culture in the last 40 50 years is a postmodernist belief system that's relativistic about truth so people don't think there is such a thing as absolute truth in science or religion or anything and so people so nothing is forbidden and anything can be done sure and I think that anything goes you know type of approach has has heard us in Psychotherapy yeah I think from the perspective of psychotherapy what what's interesting about this is this postmodernist

7:01 relativistic eclecticism has allowed Psychotherapy to happen you know anyone can do anything so they can do psychotherapy but it also doesn't justify so when push comes and people say well why are you doing Psychotherapy or why are you doing this Psychotherapy usually with this kind of thinking you really don't have an explanation except for I like it or in my experience it works and uh you know you can't get insurance companies to pay for that that if that's relevant now you can't get the government to subsidize it often you know it is important separate from the inherent reality of it's good to know the truth it's also practically important to be able to justify what you're doing which you really [Music]

7:47 [Applause] don't much of your work and your career to my understanding has has been on bipolar illness manic depressive illness as an expert in mood illness can you tell us a little bit about what role if any Psychotherapy plays in the management of bipolar disease in the case of bipolar disease like schizophrenia these are the two conditions in Psychiatry that are diseases that really are almost completely genetic in their ethology they don't happen unless you have the genes they're completely biological in their cause they're a medical disease like any other medical disease you would think that therefore medical or biological interventions would be the

8:34 most relevant and they are relevant but nonetheless there is a role for psychological interventions for both conditions in both cases schizophrenia and bipolar illness it's been shown that certain kinds of psychotherapies added to the right medications do improve the course of the illness to some extent and in bipolar illness specifically Family Focus therapy developed by David mclo and colleagues which reduces expressed emotion uh seems to reduce the life event stressors that trigger mood episodes cogni behavioral therapy probably can do the same thing interpersonal therapies been studied U so there are various therapies that may reduce the likelihood of Life events causing mood episodes essentially based on ameliorating the patient's experience

9:19 of those life events that's probably the main role for psychotherapies for bipolar illness it is not a treatment of the disease it is not really a treatment of an episode it's more in course of the illness to reduce the likelihood or severity of episodes in relation to life events yeah know you you mentioned there you know that you put in the category of psychiatric disease schizophrenia bipolar illness and you know I've read uh some of your work uh you know kin's distinction between psychiatric disease and and clinical picture or clinical entity and have come to agree you know that there's probably a core set of BSM diagnoses that reflect biological disease entities and then the other

10:06 things that are included in the DSM the majority I I would submit of the diagnostic constructs that we use are more in line with what kin would call sort of a clinical picture or a clinical entity you know psycho ideology of these problems largely psychosocial or not as inherently biological as these disease St now would you add anything at this point in time to you know schizophrenia and bipolar illness in in that latter category would you say Melancholia would you say obsessive compulsive disorder yeah you know I insist on the disease concept uh even when we talk about Psychotherapy because I want to get away from the eclecticism that you can believe whatever you want to and I think it's important for our field to admit

10:52 that there are such things as diseases of the mind that Express themselves with psychiatric symptoms and also to admit that there are not and it's not really legitimate to say everything's not a disease or everything is a disease we should be able to say which is and which isn't and in fact as you point out as as I've argued if even if you accept the disease concept if you look at all the different clinical presentations a psychiatric clinicians probably 90% are non- disease so even the diseases is a small group but that small group is really important schizophren is 1% of the population bipolar is 2% so talking about 3% of the general population have these diseases and that's a lot of people it's important to diagnose and treat them well I will say that I don't think that

11:37 DSM has identified these diseases at all or or well maybe schizophrenia but when when I say bipolar is a disease I don't mean that the DSM definition of bipolar is the valid definition of that disease my view of it is that manic depressive illness is the disease not bipolar illness and manic depressive illness includes what DSM calls bipolar illness this it also includes at least half of what DSM calls so-called major depressive disorder which would include people like you as you mentioned with the melancholic depressions but also people with mixed depressions uh which is not defined in DSM so I would say the the two big diseases are schizophrenia and manic depressive illness not schizophrenia and bipolar and the manic depressives includes the people that used to be called recurrent unipolar

12:23 depression and bipolar so that's one group other than that I think other disease entities that might include OCD properly defined not OCD as a as a symptom when you're manic or depressed or psychotic which is a common mistake my reading of this literature is that only about 20% of the people diagnosed with OCD actually have primary OCD the rest of them have OCD secondary to mood illness or other things so primary OCD yes usually starting in childhood chronic unrelated to mood illness unrelated to psychosis that is a disease autism even though people love diagnosing it now as a spectrum in the mildest cases um certainly in the classic severe cases autism is a purely genetic disease there's probably two or

13:09 three others so I I would say you know a half a dozen I could come up with and if you look at the old research diagnostic criteri from the 1970s which was the only time in psychiatry in modern Psychiatry that we ever tried to list diagnoses based on their validity not their reliability which is what DSM is DSM is a dictionary let's all agree to call these clinical pictures as you said in the German tradition they called it yeah we see patients like this let's just Define them okay fine but the fact that we see patients like this doesn't mean that they're diseases that's something that science and research has to show sure it doesn't even mean that they're psychologically caused they might be spiritually caused who knows you know so yeah we have 200 clinical pictures that's DSM there's probably

13:55 more but the research diagnostic criteria said less just list the ones not that we see the clinical pictures but the ones that we know are valid that means that there's evidence based on genetics and course of illness that these symptoms really are different than other conditions and they only came up with about a dozen diagnoses in terms of valid diagnoses we might have a dozen in terms of valid diagnosis that are diseases we might have half a dozen and then we have about 200 clinical pictures which we don't really know what they what they are on that basis would you make a broader argument that psychiat as a discipline ought to get back to the study and the treatment of these core diseases that this ought to be the primary focus of Psychiatry as a medical specialty our group has proposed in writing that we should go back to

14:42 clinical research diagnostic criteria as the basis for future diagnosis in place of DSM get rid of DSM stop the the reliability focus and change the focus to validity and then we would have maybe a dozen or so diagnosis that we would make and the rest would be not diagnoses that are definitive just various viewpoints that people could have and they could keep thinking about and I think we should focus on the valid diagnosis now they're not all diseases like PTSD is a valid diagnosis but it's not a disease it's an injury You could argue that antisocial personality maybe borderline personality are valid appropriately defined but they're not diseases in the same way schizophrenia bipolar they're not purely genetic they have a lot of environmental component to their ideology in early childhood

15:29 especially probably so yeah I would I think we should focus on these valid diagnosis some of which are biological diseases some of which are psychologically caused and the doesen diagnoses would provide I mean in reality I think the majority of clinicians do engage with these dozen or so diagnoses most of the time anyway and the other 200 labels are are just made up and or worthy of dropping I would say including add which I do not think is a valid diagnosis at all in adults or children yeah I I would agree I think the vast majority of the people that I see I think we're probably treating these maybe eight 12 15 you know core problems and sometimes without really even realizing that that these are the

16:15 issues that you know that the patient has it leads to my next question about diagnostic hierarchy and this is something that frustrates me a great deal I often see patients referred to me sometimes by by psychiatrists who come to me with four or five or six different diagnoses and uh my my understanding of the history of Psychiatry is that this is an artifact of the DSM classification system that historically you know the idea was that the patient really can have only one mental disease maybe they may have a couple of mental diseases but this idea that a patient may have five or six seven different disorders of the Mind is really a novel idea in

17:01 Psychiatry I think right so you know this is this is one of your major contentions can you just tell us you know in general why you think a diagnostic hierarchy in Psychiatry is important what what it means what is a diagnostic hierarchy and give me an example of an egregious error you know in this area if you don't mind in general in medicine the approach that's taken is a so-called differential diagnosis approach patient presents to a doctor with usually number of symptoms fevers chills night sweats and then the doctor makes a differential diagnosis of the kinds of conditions that can cause those symptoms bacterial infections viral infections other things and then he goes through that list and rules them in or rules them out if you know the cause that's the best way to go but

17:47 often you don't know the cause and the way you do it is there are some diagnoses you know valid diagnoses that have that cause lots of symptoms and you want to rule them out before you diagnose smaller condition I that cause fewer symptoms so a doctor doesn't say you have fever disorder chill disorder and night sweat disorder when you go to them with a pneumonia but in Psychiatry we say you have ADD generalized anxiety disorder and MDD when someone shows up with cyia then the cyia causes mannequin depressive symptoms which makes people have poor attention poor sleep mood being down sometimes and anxiety and instead of diagnosing the illness that causes each symptom we diagnose the effects of each symptom and then we give them three labels and say oh poor you

18:34 you have three disorders and then we give them one pill for each disorder which is really a pill for each symptom instead of treating the underlying cause uh with one pill we treat this the effects with three so poly diagnosis poly Pharmacy more harm to the patient and only in Psychiatry is this done rest of us and does not function this way and the reason is again DSM dsm3 DSM 4 the leaders of those groups taking an Eclectic post-modernistic relativistic approach said we don't know what causes anything so we can't say that you should rule out this before you diagnose that the only exception they made was schizophrenia but other than that and they so they they explicitly told people to make as many diagnoses as they could

19:19 just based on all these symptoms and because the symptoms are listed in ways that they overlap then people would make multiple diagnoses so for instance half they symptoms of GAD are the same as the symptoms of MDD you diagnose one you're going to diagnose the other and that leads to this false comorbidity problem that people have been debating now for decades sure [Music] sure I want to now you know turn to to some you know specific disorders and and just get your thoughts so if you're you know if you're seeing a patient clinically you're trying to figure out whether this patient has a cyclothymic temperament or a borderline

20:05 personality can you give us some tips that you utilize yourself in in trying to make this uh distinction because there's a quite significant overlap I think misdiagnosis when it comes to borderline pathologies and and and mood illnesses I think it goes both ways and you can you help us clarify this yeah I think I need to take a step back and first explain briefly the concept of validity and the criteria we use for that so it's not enough to look at symptoms which is vast majority of what DSM does we know in general in medicine that you can have the same illness with different symptoms or different illnesses with the same symptoms symptoms overlap you can have chest pain and it can be pneumonia or it can be a heart attack you can have headache and

20:50 it can be a brain tumor or it can be you know an endocrine problem so you can't go by the symptom to say say what the diagnosis is in Psychiatry DSM does that because it claims it's quote unquote a theoretical it doesn't know causes of things but really it's just being post-modernistic relativistic it doesn't want to know the causes of anything the validity is based then not just on symptoms you have to have other sources of evidence in medicine we have pathology as the ideal Source appropriate laboratory tests so on Imaging in Psychiatry we don't tend to have that the other two sources of evidence besides symptoms and pathology would be course of illness how the illness goes over time when did it start

21:36 what it age is it episodic is it chronic does it improve does it not by natural history and then genetics in the case of diseases that are genetics genetic that can be helpful of course many conditions are not genetic so these are the four validators symptoms genetics course of illness and biological markers if you have them now in terms of differentiating cyia and borderline personality the symptoms won't do it for you because they overlap we have movability in both cases and everyone debates that and that's a waste of time and it's DSM falsehood that's ruining the field in terms of biology biological markers we don't really have the testing for that but we do have course in genetics cyia is genetic it's part of manic depressive illness which twin studies show is almost completely

22:21 genetic 90% genetic in cause borderline personality is not primarily genetic it's about half genetic based Bas on the twin studies half environmental so if you have family members with bipolar illness severe unipolar depression then that makes the patient much more likely to have cyia than borderline personality if you turn to course of illness patients with borderline personality have sexual trauma in two-thirds of cases defined by DSM definitions which does not require sexual trauma but if you look at older definitions it's probably even higher than that and in cyia and man exessive illness it's 20% Which is population Baseline so it's three times more likely or more if you have borderline personality terms of self-cutting which is another course

23:07 kind of symptom actually partly but also course issue you see that with borderline personality in two-thirds of patients again cyia hardly any so if patients have these other features of self-cutting or early sexual trauma they're much more likely to have borderline personality than cyia so the answer is forget the sympt look at the course and the genetics and differentiate it based on those features it's very helpful and lastly you know your comments on adult ADHD actually our comments I've written a piece with you on this topic you know they've garnered a lot of attention and since we're talking mainly to psychotherapists here you know for the general practicing psychotherapists you know what do you think it's important for them to know

23:54 about this disorder adult ADH D recent Trends in this regard it seems like every other adult patient that I'm seeing now is coming in and saying I have adult ADHD I've been told by my psychiatrist I do or gone online and I took a 10-minute screening test and they wrote for me for a stimulant what's important for the average practicing psychotherapist out there to know about what's happening with adult ADHD right now in our society yes well I mean I think the interest in the diagnosis is expanding because dsm5 in 19 in 2013 expanded the definition and this is exactly what the DSM leadership wants they basically want to manipulate the society to believe in psychiatric diagnoses the way they want them to

24:41 believe so they expand a diagnosis and then people believe in it it's it's very much of a herd mentality I think the issue with adult ADD is that it basically takes a symptom or a set of symptoms executive dysfunction and poor attention and it makes it a diagnosis whereas executive dysfunction and poor attention happens with a bunch of other diseases or diagnosis legitimate ones like depressive States manic States and psychosis and even anxiety States they all impair executive function and reduce attention and uh so if you had adult ADD in if there was such a thing you'd have to show that it existed in people who don't have those other conditions when you look at the research on that in studies like the national comorbidity

25:27 survey 80% at least 80% of people diagnosable with adult ADD were also diagnosable with a mood illness another half of them were diagnosable with an anxiety condition so it's almost impossible to find people that meet so-called adult ADD definitions who don't have mood illnesses and anxiety now the add experts will say they reverse the causality they say the add causes depression and anxiety well they have no proof of that that's just their belief about half of them have Mania how does does a cause Mania no one who legitimately would claim that so I think that the diagnostic hierarchy approach is one reason to doubt it the other thing is when you look at prospective studies of adult ADD the claim is that these are children who have it continue to have it into adulthood and it happens

26:14 in 3% of the population there are prospective studies that have followed children into adulthood multiple ones and they have a control group so you know who does and does not have it as children and you know who does and does not have it as adults you get the 3% number but the interesting thing is the majority of them 80% did not have it when they were kids so it's not adult ADD when they're distractable and have poor executive function so as adults because they actually didn't have it when they were kids it they have poor executive function but it's not so-called adult ADD so when you look at the course of illness as a validator it does not validate the diagnosis the symptoms don't validate it there's no biological markers that differentiated from other conditions when you look at genetics and the huge gws studies there's a huge overlap with so-called

26:59 MDD and bipolar it's not specific to add so nothing validates this when you look at the validators I think psychiatrists like to diagnose it because they like to give people amphetamines amphetamines improve your attention right away everybody's happy everybody gets paid and you know patients like it and so they have a little rationale for doing that even though amphetamines are they don't tell people and they don't know usually that amphetamines are harmful to the brain they kill neurons they NE toxic in animal studies all repeatedly and in humans they haven't been shown to be safe um the only reason we have them is because they were grandfathered into use before the FDA started regulating drugs for safety and efficacy in the 1960s so for psychotherapists what's relevant then is that a lot of people

27:45 will come to you with this claim that they have executive dysfunction and poor attention the culture has set it up through dsn5 for them to be able to say that that therefore that leads this diagnosis of adult ADD and then they'll want maybe referral or or treatment for it whereas the right thing to do is to look for the ad to 90% that actually have Moon illnesses or anxiety States and diagnose and treat that very very helpful and then my my final question for you is is a hierarchical you know question and I I want to know in your opinion where personality disorder falls in the psychiatric diagnostic hierarchy I've seen some people place it at the very bottom now my problem with this personally is that you take a patient

28:32 with dsm5 defined borderline personality disorder you can see problems with mood you can basically see any axis One symptom in borderline States so why would we place that at the very bottom of the hierarchy when we ought to be considering something like a borderline personality in the patient who comes in with depressed mood with anxiety with transient psychosis and the like so where do you place personality disorder in general in the hierarchy well just because something's at the bottom of the hierarchy doesn't mean it's it's less important it just means you need to rule some other stuff out too and you you may be able to rule them out for various reasons like I said the biggest reason is the other conditions may also may have more symptoms they capture more

29:18 symptoms but it also may be that they're treatable for instance in different ways so for instance yeah you say borderline personality captures all the symptoms so does bipolar illness so does man manic depressive illness find replan way it captures every symptom in Psychiatry so that ought to be ruled out for everything first before you diagnose something else you will mistakenly make the diagnosis of borderline personality if you do not rule out manic depressive illness especially because we already know in the past that when you're in a mood State you can look borderline when you're depressed for instance and there are studies that have shown you know so-called coorbit borderline and MDD you follow them for a year half the borderline personality goes away so it wasn't borderline personality it wasn't just the depression but an important point is also these mood temperaments

30:04 which we mentioned like cyclothymia and hyperthymia which most people don't know about it's not DSM being manic all the time as part of your personality these are not episodic they don't come and go they're there all the time and so they produce anxiety and poor attention and that gets misdiagnosed as ADD adult ADD as we talked about so when we talk about that add issue maybe just mentioning this again it's not about ruling out quote unquote bipolar and saying oh no it's not bipolar because they're like this all the time you haven't ruled it out because with manic depressive illness mood temperaments they're like that all the time so a lot of these add patients actually have cyclothymia same thing with Gad they can have hyperthymia as well same thing with borderline patients your mood is up and

30:49 down all the time cyclothymic you know you have unstable relationships cycy Etc the things that are different or the course of illness features I mentioned which is childhood sexual trauma and self cutting be the most prominent also dissociative States certainly are different between the two so you have to rule out the the cyia the hyperia the manic pressive illness before you even start talking about borderline personality but it can be you can rule it out and maybe they don't have the genetics and they have the self cutting and they have the other features that would be more classic for borine personality I will say this about personality disorders in general I don't think that the concept is valid again it's just it's been living with us for 40 years so it's easy to accept it but we just have to remind

31:35 ourselves nobody ever thought of the concept the term didn't exist before dsm3 in 1980 the term personal disorders was invented to create a place in DSM for psychoanalysts to continue to practice that's the reason so-called axis 2 was invented when dsm3 was going through the process of getting voted at the APA there was sudden in the relatively later stages um a lot of resistance from the psychoanalytic establishment which was in 1980 very powerful in Psychiatry and they would not pass dsm3 unless they put in a section that would allow them a way to allow them to get reimbursement for psychoanalytic therapy which at the time was reimbursed by the way by Insurance very well and they invented personality disorders as a way to do that the concept of borderline personality did

32:21 exist beforehand the concept of antisocial personality existed but none of the other personality quote unquote disorders existed before them the idea of the terms were there people were called narcissistic they were called dependent they were called avoidant they were called schizoid but those weren't viewed as personalities or personality disorders as I would kind of say not just that the issue about the hierarchy I would just say the whole concept is not proven or valid and in fact DSM 5's personality stores task force was going to take out all the personality stores because they're disproven most of them are disproven except for borderline and antisocial and it was kept in only because John Gunderson who founded the borderline concept and others letter a letter writing campaign that led the border of Trustees to change their minds so there wasn't really a scientific

33:07 reason for it so I think the concept of personal disorders is not a good one necessarily from a scientific perspective and that's another reason not to have it high on hierarchy when you're using an invalid concept well Dr gami this has been very enlightening great history lesson for us and and wonderful uh clinical insights so I really appreciate your time with us on the podcast today nasier gami of tus Medical Center Harvard University World expert in bipolar disease lithium therapy philosophy of Psychiatry thank you so much for joining us Dr gami thanks Mark check out the carlot Psychotherapy report for valuable insights into Psychotherapy and social work you can access it online and sign up for email

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