Friday, January 19, 2007

The Well-Worried Well

Psychiatric and psychological treatments are used to address a number of issues including, but perhaps not limited to: the symptoms of designated syndromes of mental illness (for example, schizophrenia, affective disorders, anxiety disorders, attentional problems, personality disorders), the behavioral consequences of symptoms of psychiatric disorders (such as crawling under the covers while depressed, promiscuity while manic, homicide while delusional), primary behavioral problems ( such as substance abuse, gambling), maladaptive patterns that may arise outside of a mental illness (Why do I always end up with creeps?), dissatisfaction with life circumstances (I haven't lived up to my potential), difficulties coping with life stressors which may or may not precipitate a psychiatric illness and sometimes are the focus of treatment even in the absence of illness (grief, adjustment disorders), or a desire to gain insight and understanding of one's self as a goal of its own ("The unexamined life is not worth living." Thank you, Socrates). That was a really long sentence. In short, and to use the lingo of my former chairman, Psychiatry looks at issues pertaining to mental life and behavior.

If you hang around long enough, the term Worried Well gets thrown about. It refers, I think, to those folks using psychiatric treatment to broaden their insight, to maximize their functioning (so why am I still driving a cab when I have a graduate degree?), to lead richer lives. It may refer to people suffering from Anxiety Disorders, rather than the more "serious" illnesses such as schizophrenia or bipolar disorder It refers to the stereotype of the neurotic, sometimes Jewish, New York, Woody Allen characters who obsess and worry --though I will point out that Woody makes criteria for many diagnoses very quickly. It sometimes refers to those suffering from Major Depression who should just pull themselves up by those blessed boot straps. Actually, I'm not really sure who exactly those Worried Well are.

The Worried Well is a term used, even by or especially by, psychiatrists with a bit of disdain, especially by psychiatrists who treat severe, chronic, and persistent mental illnesses. The broader question embedded in the subtext of the term begs: Who Warrants Care? How do we allocate our resources? What is worthy of the psychiatrist's time and attention, and who should foot the cost?

Most of the people who come into my office arrive while suffering. Suffering, it seems to me, warrants care, even though I'm occasionally left to say, "You don't have a mental illness." Suffering is sometimes just a part of life and life is often hard. Psychotherapy often helps, for reasons which remain a bit vague to me, sometimes medicine even helps in the absence of a mental illness (oh for a good night's sleep, or something to help that post-9/11 gotta-get-on-a-plane nervousness), but there are those who feel that psychiatric resources--especially those paid for by a third party-- should be limited to those with major mental illnesses.

It's a nice idea, but the lines get blurry. The more common scenario is that someone arrives in the midst of an episode of mental illness. They get better, usually fairly quickly. No longer in the throes of acute, intense, and miserable symptoms, the patient often continues to come on some regular basis. They still need their medications monitored, but it's more than that. Sometimes patients are afraid to stop coming-- fearful their symptoms will recur. Often, they say they feel better after a session. Many have periodic mini-flares in their symptoms-- normal variations in mood perhaps because moods do afterall vary some, but once someone's had an awful episode, they can get very sensitive to even little changes. Sometimes, it's simply hard stuff to articulate. And honestly, I've followed a number of people who show up regularly to talk about the stuff-of-life, who come despite a lack of symptoms, who at some point later on develop raging symptoms. Sometimes it's about alleviating symptoms, sometimes it's about preventing relapse, sometimes it's about holding on for the ride. Sometimes, I don't even know what it's about.

Does it need to be articulated? We take children to the pediatrician when their ears hurt. We don't say, oh it's probably viral, I won't waste the doc's precious time. How many unbroken arms get x-rayed, how many normal brains get scanned in patients with unremarkable neuro exams? And what about the zillions of screening mammograms and then diagnostic biopsies on all those women who
will never get breast cancer? Or the all those PSA's for men over 50? Many conditions get better without treatment, but we don't begrudge anyone a medical evaluation to be on the safe side.

I sometimes (-not a lot, the folks who wander into a psychiatrist's office are a self-selected crew) say "You don't have a mental illness." I've not yet said to anyone who's walked in while suffering, "Don't come for psychotherapy."

P.S. If you have the answer, by all means, comment!


DrivingMissMolly said...

This is a thoughtful and provocative post, Dinah. I'm going to go out on a limb here and comment.

You ask; "Who warrants care?"
Anyone who seeks it. I don't think you could round up a group of people and find many that would voluntarily go to see a shrink for no reason. Our culture sustains an expectation that each of us will help ourselves with a minimum amount of disruption. That is, we take care of our problems ourselves. We pull up our own bootstraps. We rely on ourselves.

There are people who say they have pain, but the docs can't find a reason. Does that mean they are not entitled to care either? So it is with psychological pain.

Let's say a patient comes in and they aren't suffering, per se. Their reasons may not be legitimate to you, but they obviously are to the PT. So, because you can't find a DX or perhaps the DSM doesn't have one, that means they don't have an "official" illness, so their need doesn't count?

We all know that the healthcare system is broken and nothing makes sense, or if it does, it makes little sense. For example, my life insurance, should I kill myself WILL pay my beneficiaries $100,000, but my medical insurance has a $2000 deductible for my out-of-network psychiatrist, so, basically, I am paying $190 a visit out of pocket.

What does that say about the "value" of my life? I keep going to the shrink because I don't want to hurt my father and siblings, and now I have a baby niece, but if it were up to me, well, I think you know what I'd do.

As to "what is worthy," I guess it depends of what kind of psychiatry you practice. Some people might think that Clink's patients aren't worthy. After all, they've committed crimes against society so, why should they get psych care?
What about the sickest of the sick? Maybe, since their prognosis is poor, we shouldn't "waste" any resources on them at all.

Obviously these are some things the profession has to work out, just like any profession that provides an expensive service such as law, accounting, etc.

All I can say is that you better work it out as a profession because if someone else steps in, like a government official or some new policy, they wer're all f***ed.


DrivingMissMolly said...

PS Sorry for the typos, I swear I proofread, but my coworker came in with GS cookies so all bets were off as I wrote.....


NeoNurseChic said...

As long as people still commit suicide who aren't depressed, then anyone who seeks care should receive it, regardless of whether or not they lack a diagnosable mental illness.


Take care,
Carrie :)

NeoNurseChic said...

Oh and by "aren't depressed" I mean "aren't suffering from depression." There is certainly a difference! Everybody gets depressed from time to time - but not everybody gets depression. Know that I don't need to write that here, but still - wanted to clarify what I wrote - lest someone think that I believe that many suicides are committed by perfectly content people. LOL

Sarebear said...

but there are those who feel that psychiatric resources--especially those paid for by a third party-- should be limited to those with major mental illnesses.

It's a nice idea, but the lines get blurry.

I strongly disagree that it's a nice idea, even.

See, I've seen an attitude on various mental health blogs and stuff, that psychosis, shizophrenia, and such, are the really interesting things; the reason many go into psychiatry, even the only worthy things, like you are saying many think . . .

THAT is hogwash. Not the part about them being interesting, but the rest . . . the attitude about them being fascinating, though, I think tends to elevate them to the other attitudes, at least I feel it contributes greatly.

People are people, and suffering is suffering, and if someone is suffering enough to come in, hey, pay attention. Yeah, there's hypochondriacs, but hey, for psychiatrists, that's not got the "made up" issue that it would for a hypchondriac thinking they've got a zillion physical illnesses that they don't have, going to their family doc. Ie, it's a psychiatrically treatable problem.

But that leads me into something else, that I've read about and seen on various mental health blogs and sources; the disdain for those with personality disorders. I guess some of them are hard to treat, or don't have many, if any, treatment therapies or options or whatnot. They aren't seen as mental illnesses (I guess since they are "disorders", problems of thought, personality, whatnot), but I say that these people DID NOT CHOOSE the crap that happened to them when young, that led to the development of such disorder(s) in them . . . . this stigma from the only people who could help them, I think is absolutely AWFUL. It's HORRIBLE!!! I think more should be done to fight that sort of thing, within the professions of mental health providers. There's more to mental "health" than fighting illness.

Let me say that again. There's more to mental "health" than fighting illness.

No matter how annoying or horrid someone's behavior seems from a personality disorder, or from having features of that disorder, that person did not CHOOSE to become that way, and in fact, may have wanted help their entire life but fought against the impulses and urges and stuff their entire life; may have fought to "keep a lid on" the negative aspects of their personality, and often run out of the mental energy to keep that lid on . . . and then get seen and judged as "bad".

Anyway. I think even beyond who warrants care, those who come in, kinda thing, is a larger issue too of those who never come in, who really could use some help. Yes, this includes those with mental illnesses, but includes many others, too. But with stigma and prejudice inside the professions, I don't think it can ever be effectively begun to reach out to some of these who never come in . . .

*off my soap box now*

Oh yeah what dmm says, about pulling up by our own bootstraps, which you also mentioned . . . when someone could really benefit from some help, this attitude really causes alot of damage, sometimes.

I applaud you for your feeling and philosophy that if they come in to see you, they are probably/possibly/likely suffering "enough" to benefit from whatever you can do for them. THANK you for psychiatrists like you!!!

Lily, thanks so much for your comments.

And gimme some of those GS cookies, and no one gets hurt (tee hee!!)

ClinkShrink said...

DMM is right---we better work it out as a profession. Unfortunately, we're not so third parties are stepping in. I would never suggest that someone with suffering doesn't deserve care. The big question is---what do you do with the last group of folks that Dinah blogged about---the folks without symptoms who come in to talk about stuff-of-life things? How do we as a profession 'work it out' with these folks to protect the suffering ones from third party interference? Do you tactfully suggest they shouldn't come anymore unless there's a 'real' problem (and IS there a tactful way to suggest that? I don't think so.)

And by the way, I want everyone to know what a wonderful friend Dinah is. She called every day for a fever-and-sputum report during my down time. It's good to be back on my feet---er, typing fingers---again.

NeoNurseChic said...

Reading some of the comments and the post again has led me to recall some things in my own life that I've always kind of puzzled over. I don't think adjustment disorders get a lot of press. I don't think I still, to this day, understand it. I mean - does that mean that somebody had something happen to them and they didn't adapt in a positive way? They became possibly anxious or depressed, but not to the point of having clinical depression or anxiety, but still in an abnormal response to things in life because they didn't adjust to something that happened?

The reason I ask these questions is that the time I was able to go to a psychologist when I was in high school, I was diagnosed with an adjustment disorder with mixed anxiety and depression. I've somewhat recently read over parts of my diary that I kept during that time... In my own mind, what spurred me to feel so darn depressed and confused about life was having a tumor when I was 16. I hated that my parents would say to the doctor, "What if it's something more serious?" and mean "What if it's cancer?" but not say "cancer." And I was lucky, because it wasn't cancer. But then, within weeks of my having the tumor removed, my best friend's mom got diagnosed with cancer. So then I was all messed up - I would be up at night wondering why some people get cancer and some people don't...and trying to figure why I was lucky enough to get a benign tumor when my best friend's mom got a cancerous one.

But it wasn't just that - 4 days before I had my tumor removed, my father was almost killed in a very serious car accident - and I was the last person to talk to him from our family before it happened. And what's more is that I didn't think anything of it when he wasn't home 2 hours after he said he'd be home - when he was only a half hour away at the time he called me. That's because my dad has traveled for work for my entire life. He never comes home at the same time every night. Not sure if I've carried around a lot of guilt from that or what - it's not like there was anything I could have ever done about it. I couldn't prevent someone from running a stop sign at 55mph and barreling into my dad's car.

But the consequences were mighty. He had all kinds of stitches in his head and had a broken foot and knee. Then, 2 days after my surgery as I lay in my parents' water bed conked out with my face looking like a MACK truck hit it, my father fell down the stairs and broke his arm. I was the only one home at the time. I didn't even realize it really. My mom and brother came home and my dad's arm was the size of a football. They took him to the doc and he came home in a cast - with a wheelchair. His boss, who was a complete a$$ - later fired him and my dad was out of a job. And an ortho committed malpractice on my dad's foot after the accident, so in the end it took him an entire year to recover the foot instead of just a few months. We didn't sue - we have never sued for any of the things that have been done wrong and resulted in bad outcomes. (For the record, my best friend from high school still has no feeling in one finger that was broken by her sister slamming a door on her hand - and she went to the same doctor and again, bad practice resulted in her losing the feeling in the tip of the finger...the guy's terrible, IMHO...)

And then 2 weeks after my dad's accident and my surgery, my brother broke his back playing soccer - for the 2nd time. (Stress fracture in L4-5, I think...) I remember how upset my dad was when my brother couldn't play. I remember feeling like my dad was more upset that my brother couldn't play soccer than he was about me having a tumor. I actually finally told my mom about how I felt when I was in the hospital for my knee surgeries in 2005....8 years after the fact. I think our family really got stronger from all this happening at once. But it sure was hard!

All that happened when I was a sophomore in high school, and I didn't go see a psychologist until I was a senior. My guidance counselor recommended the name of a couple of adolescent therapists to my parents, and I forget how they ended up picking one. But anyway - I remember listening at the top of the basement steps as my dad was down in his office, telling the therapist about me and his version of the reasons for why I needed to talk to somebody. I remember him mentioning the car accident and my brother breaking his back, but he didn't even mention the surgery I went through. Surgery to my face... When I was 16. For a golf ball sized tumor. So after he got off the phone - later that night, I said that I'd heard what he said and I didn't understand why he wouldn't mention my having surgery for a tumor. And he then said to me, "You didn't have a tumor. I didn't believe the doctor when he said that." Huh?! I wish we could just not believe what doctors say sometimes when we don't want to accept bad news...

Did I maladjust? Maybe... lol I'm sitting here in tears as I'm typing this story...shaking like a leaf. It's been a long time since I told it like this and thought of it this way.

But what sticks in my mind is that how does one adjust to these things? Bad things happen to people, and unfortunately, when they happen when you're younger, you don't really know how to deal with them. Is there a right way to adjust? Should I have just grieved a few things and moved on? Why does this still bother me, 10 years later? Does it warrant psychotherapy even if it didn't mean I was clinically depressed or diagnosibly anxious? I would hope so....

For the record, when I went to college, I had the funniest mental health experience. I went to the student health center and met with this intake counselor. She pulled out the DSM-IV and found the criteria for GAD and read down the list and said, "Do you feel ___insert criteria here___" and when I had answered enough questions, she said, "OK. You have generalized anxiety disorder, and I think you need to see a psychiatrist and take medication." I refused to do that, so I saw a psychologist (student) instead. In my first appointment, he said to me, "What do you think in your life went wrong?" I just stared at him - trying to take in exactly what he meant by that question. I never went back. Saw another counselor a few years later, but she really was just so focused on having a goal - so I made a few goals, and when those goals were accomplished, I figured I didn't have a reason to keep going (because I couldn't establish clear enough goals), so I quit going again. Now that I see my current psychiatrist, my diagnoses are instead ADD - inattentive type and Depression, NOS - which I fondly refer to as my 314.00 and 311.

Diagnoses - do they make a difference? Do they define me? Perhaps to the former, no to the latter. I'm a person - I have a collection of life experiences. Most of them great - some of them not so great. I might be talking about the not so great here, but mainly to illustrate the human picture of a "diagnosis." I am a life story...same as everybody. My experiences are unique to my life. While other people go through the exact same circumstances in various ways, my brain has me experience it in my own unique way. So how do you take the stories of someone's life and put it in a diagnosis? It's easy if they fit strict criteria from the DSM-IVtr or whatever the version is these days. In fact, it would be easier if I had presented with straight up clinical depression or some other very straight forward issue. It was easier for that nut-job intake counselor to read down the criteria for GAD than to ask me why I was there and to listen to my story.

So we can diagnose and compartmentalize all we want - but I suspect that all of us have a story. We could probably put a diagnosis on all of us in some way, no? I still kinda wonder how I was supposed to adjust. lol I just think that even when I didn't fit the specific pathologies of something MAJOR wrong (and I'm very glad for that...) in the psychiatric department, I still needed help. I was still feeling alone, confused, scared, angry, happy (yes, even happy can be bizarre, at times!), mixed up, teary, etc when going through hard times. And I think it's okay to ask for help during hard times instead of just telling people they have to have some sort of "real" problem. After all - our problems are all real to us - just as pain is what the patient says it is.

I thank you (all 3 of you, really!) for being a good psychiatrist - at least as far as I can tell from the blog, since I really don't know you in a clinical sense - but I think what you write says a lot about your character and philosophies. I don't particularly care for the phrase "worried well" because it is kinda like "hypochondriac" in the medical world...or whatever phrase ya wanna throw in there. It is supposed to label those who the doctors and nurses don't really want to work with - or maybe just the ones they don't know how to help - but nobody wants to admit defeat. I'm glad that you don't view anybody that way and that you are open to working with all people, if they ask for help. That reminds me a lot of my own psychiatrist. Many times I have said that I think my own problems are not that bad and that I'm whining a lot over nothing when I know plenty of other people have it way worse, and he has said to me many times, "But what if all that matters to me is what is on your mind and what happening in your life right now? It doesn't matter how it compares to other people." Nice...

I wish we all had a psychiatrist/therapist/etc like that.

Sorry for the long long long comment/rant/whatever. For some reason, I felt compelled to say that!

Take care,
Carrie :)

NeoNurseChic said...

One last thing (and then I'll shuddup - I promise!!) - can you enlarge that cartoon? I had to squint and put my nose to the screen to read it! It's quite funny!!! :)

Take care!
Carrie :)

alwaysthegoodgirl said...

Great post. Thank you for sharing issues within the profession. It's good for those of us who aspire to be a psychiatrist to know about them.

jcat said...

Good post, and really good response from DMM.

From my perspective, current p-doc has such a queue that he pretty much tells patients roughly when he thinks he should see them again. So if I ever get to not feel like sea mud again... hey if that happens I can live with not seeing him.

T-doc and prev p-doc, with both of them I developed a sort of routine. When it is really bad I see them anything from 2 to 5 times a week, depending on being in hospital or not. In between, by my choice and at my cost, I used to always see both about once every month to 6 weeks. Ex p-doc once asked me why, given that we basically sat and talked bull for an hour. Eventually I worked out that it was important to me that they both know me when I am not a total loser a*hole, that maybe they see that in between I can be smart and funny and energetic sometimes. That sometimes I don't spend every day crying and cutting and other loser activities.

And also, because as a bipolar MDD kind of recurrent loser, whether I like it or not, I have given up on believing in happy ever after. Ever after has been anything from 4 days to more than a year. But it always ends sometime, and when it does, it helps that p-doc/t-doc know roughly where I've been and what I've been doing. Cos sure as shit I can't express myself well enough then to explain it.
There are so many things that I am excluded from potentially because I see/have seen a psychiatrist. I can't conceive that there would be many people who overcome the stigma of that just for fun.
Tx for lots of good and challenging posts.

Anonymous said...

Very thought provoking post, Dinah.

I think that most people don't think of going to see a psychiatrist as their first line of response after a major crisis. it seems to me that most people don't go to see a psychiatrist (or at least have an appointment in the community) until long after the acute psychiatric crisis is over.

I guess I'm an example of this - started with my psychiatrist as an elementary school student - 2 1/2 years later, bang, had my first real episode of depression. I'm just thankful that I happened to be a patient of this psychiatrist, or else it would have been near-to impossible to get long-term care in the community.

The last thing I'll say is that I don't think there's a cut and dry answer to this conundrum. I've taken my share of ethics courses, and have done a fair amount of reading, but I don't think the use of cost/benefit analysis would address this problem. Like someone already said, even if the psychiatrist doesn't perceive the patient to have a diagnosable mental illness, that doesn't minimize or change the amount and intensity of suffering or pain that a person feels.

The answer to this question, in my opinion, lies in the bridging of services, so that people can seek care from other mental health professionals (such as psychologists, RNs, RPNs, MSWs, etc) but feel confident that should the situation escalate, the possibility of being supported by a psychiatrist is there.

sophizo said...

I agree that when someone comes in suffering, they should be treated, but your question is how to allocate resources. What I learned when I worked for a psychiatrist is that their time is very precious and many psychiatrists just don't have the time to sit 1 hour a week to give therapy to everyone. It's not that they don't want to help the people in need, there are just so many people in need of therapy and not enough psychiatrists to do both meds and full therapy. I noticed this is especially true for child psychiatrists (who I worked for) and even more so for those that specialize is very specific areas in psychiatry.

I think it may be better to make comparisons to seeing a "specialist" rather than just a general practitioner for routine tests. I don't see an orthopedic every time I sprain my ankle, rip a muscle, or get some other bone injury (which is ALL the time!). I see my PCP until my issue(s) warrant a visit to a specialist and if indicated, all follow-up appointments are with my PCP. Psychiatrists are specialists and even if we don't like it, insurance companies understand this. Not everyone needs a psychiatrist. Maybe for meds, but not necessarily therapy. A qualified therapist should be just fine. Even with meds, the more simple problems (I'm not talking illnesses here) can be taken care of by a PCP after an initial consultation with a psychiatrist and then a therapist can take care of the therapy.

To comment on Clink's comment...I truly think you can tactfully suggest that a patient doesn't need to be seen as often or just for therapy. Why can't you suggest that you're proud of how much they've progressed and feel that at this point in treatment, a team approach would be in their best interest? I don't mean just drop the person, but gradually transition them to a therapist for the continual/maintenance talk therapy. I can understand that might hurt at first, but wouldn't a gradual change lessen the initial blow?

Maybe I'm not understanding how hard something like that might be for a person who doesn't have a "major" psychiatric illness and is now past their initial suffering. What I do understand is how desperate some people are to get into a psychiatrist, but can't because those who only come to talk about general life issues take up those appointments. I used to get (at minimum) 2-3 calls a day asking about getting an appointment (even though his machine specifically states he isn't taking new patients). They would beg and plead with me when I would call back with recommendations. Sometimes the guy I worked for would be their 4th, 5th, or even 6th try at finding someone to see. It was definitely an eye-opener for me!

DrivingMissMolly said...
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Gerbil said...

I don't know how many times I've told clients that there's little use in saying "I don't deserve help because so many others' lives suck more than mine." Despite what managed care might say, you can't quantify suffering. Even malingering is suffering, though in a backwards sort of way.

Managed care (in paying more for major mental illness than other conditions) also forgets that there is a difference between a diagnosis and a disorder. As my graduate advisor pounded into my head for four and a half years: The disorder is what you have; the diagnosis is what you call it. It's impossible to know what mental disorder someone actually has--but it's awfully easy to be misdiagnosed.

(And because I am a math geek, I feel compelled to point out that there are 256 ways to meet criteria for borderline personality disorder. Awesome.)

Dinah said...

I'm still thinking about everyone's comments, there may be a second post, and I'm not thinking about Iowa (Clink is).

The cartoon has already been blown up, it reads "It might help if you told Skippy he needs improvements instead of calling him a bad dog." I'm not sure how relevant, I just liked something about the pic.

Mostly, I agree with everyone.

Oh, and Suicidal Ideation is a symptom, a serious one, and once you have this particular symptom, no psychiatrist anywhere begrudges you getting treatment. Anyone who thinks about ending their own life is not in the category of The Worried Well.

Finally, on my quick response here before I go off to watch Lost on DVD (what a great show), Sarebear, you are absolutely right about the stigma associated with Personality Disorders and your thoughts about this are touching and poignant. Thanks.

I may have more to say another day.

NeoNurseChic said...

With regards to my first comment where I was mentioning suicide, I wasn't necessarily referring to people who admit to feeling suicidal or having suicidal thoughts. But there are plenty of people who go to therapy for stuff that maybe some would consider just the stuff-of-life...and while they might be seeking help to talk about these things which are truly bothering them, they might be feeling suicidal even if they don't admit it. I have family members who have done this very thing, and I myself did not tell ANY therapist how suicidal I felt until my current psychiatrist - even though I'd been feeling it for years. So that's why I think that anybody who asks for help should get it. Y'all (psychiatrists in general) aren't mind readers - and plenty of people say "no" to the question about suicidal thoughts....even when they're dying inside to talk about it.

Just had to add that thought - I wouldn't think a psychiatrist would turn away someone who admits to having suicidal thoughts, depression or no, but since people without depression sometimes commit suicide and may not straight up admit they are suicidal, well - we should continue to help whoever asks for it, IMHO.

Take care!
Carrie :)

Midwife with a Knife said...

I've been thinking about this one, and I think there are some worthwhile analogies in the physical health sphere.

I sprained my shoulder kind of badly a few weeks back (pulling a baby out). Had a bit of a nerve impingement and got a little physical therapy. If I had done nothing, would it have healed ok? Almost certainly. Did it get better faster because of the PT? Almost certainly. It's probably the orthopedic equivalent of the common cold. But the injury impaired my ability to function, so I saw the appropriate doctors/therapists and got better faster. The same philosophy could be applied to mental health care. Maybe people's mild mental discomfort, etc, would all get better on their own, but it impairs their ability to function, so it should be treated!

I periodicially (hah!) see patients with dysmenorrhea. Crampy periods. It can be quite disabling for some people, for others it's just annoying. For the vast majority of people it doesn't represent anything serious going on (and can be a suggestion that things are working as they should). But it's something that we have treatments for. If it bothers people we should treat it. So, once we had ways to treat it, we give it an ICD-9 code and start billing the insurance for it.

That's kind of how I feel about mental health issues. Maybe (and I may be out of my depth here) the DSM IV is too limiting. It's just the major mental disorders, right? Well, maybe you guys (psychiatrists) should come up with diagnoses for these things that strictly speaking aren't disabling mental illnesses, give them ICD-9 codes and make them billable; at least for the stuff that you can make better.

As far as I'm concerned, the people who just want therapy to examine their life more can pay for it out of pocket. Everything else, I think we should give diagnoses to and treat.

DrivingMissMolly said...

Alison, you wrote;
Um, what about borderline personality disorder? I’m under the impression the standard treatment for that is to stand there with your hands on your hips and say patronisingly, “I can’t help you. Nobody can help you. You need to learn to deal with it yourself. Now if you don’t stop bothering me I’m going to call the cops.”

HAHA. That's a good one. THEY DON'T EVEN TELL YOU THAT BORDERLINE IS YOUR DX!! Talk about leaving you in the dark. I found out by accident!

gerbil wrote;
(And because I am a math geek, I feel compelled to point out that there are 256 ways to meet criteria for borderline personality disorder. Awesome.)

Yup. I saw that on another site. If you guys haven't already, you should check out The Last Psychiatrist's take on borderlines at

Talk about stereotyping!

"like a 15 year old girl" Yeah, that's right.......

Anonymous said...

Anybody, "worried well" or not, should obviously have access to a psychiatrist for assessment purposes. It isn't reasonable to expect patients to be able to distinguish whether they are worried well or worried mentally ill.

But if someone is not mentally ill, and wants a professional simply to discuss the "stuff of life" with, then I think that a psychologist and not a psychiatrist is the appropriate health care professional to see. Anybody who wants to pay for it certainly should have access to psychotherapy if they feel it enriches their life -- just like anybody has access to paying to go to the spa if it enriches their life. But medical care from a psychiatrist, on the other hand, should be for those who are mentally ill. I do not think it is appropriate to see a psychiatrist regularly to enrich the quality of your life any more than it would be appropriate to see your family doc every week to enrich the quality of your life.

... and then in the rest of the cases, where it just isn't clear who is worried well and who is mentally ill, then it's up to the discretion of the psychiatrist to decide whether or not it's appropriate. But this isn't because the worried well need psychiatric care, it's because mental illness can be hard to diagnose, and sometimes you want to be safe rather than sorry.

Anonymous said...

I think part of the problem is confusion - on everybody's part - on where exactly to go for guidance on the "stuff of life" problems.

We've medicalized so much of life that we're trained to go to the "doctor" for everything - from what to eat to sexual issues to existential problems. The dark night of the soul isn't a spiritual moment anymore - it's something to see the doctor about, to screen for affective illness or to pick up some Ambien.

That screening may not be a bad thing, but when there's no "disease" - what next? Because the context is medical, and because the medical model has subsumed so much of our self-understanding, we have the sense that if there's no medical illness, our difficulties are less real. When in fact, we may be confronting the most profound and painful problems of existence. Death, loneliness, love, meaning. And there's no obvious next step - no clear place to go - outside of psychotherapy - no matter how inappropriate or inadequate psychotherapy may be to the task.

It's no one's fault. Cultural changes have left us with a yawning vacuum in this area, and people naturally turn to psychiatry when confronted with the existential challenges of life.

And let's remember only a few decades ago, psychiatry really did see these problems as it's primary purview. Say what you will about psychoanalysis - but it was *GOOD* at providing a place to explore and give meaning to "the stuff of life." It saw "personality" as it's fundamental task, and biological illness as a side issue, an inconvenience which got in the way of the main task of self-exploration.

That attitude was terribly destructive to people with biological mental illness, but there was also something valuable in it that's been lost - an understanding that resolving biological illness is just the start. Once biological illness is managed, the most difficult and most profound work begins.