SIG-E-CAPS

This is the mnemonic for diagnosing depression, according to our current manual, DSM-IV. Five symptoms, two weeks, seriously? Let’s review. Suicidal thoughts, are these active or passive? Perhaps they are related to a traumatic event. What if they go away in three weeks, then does the person still get a diagnosis of “Major Depression”. Interest in activities, is this losing interest or diminished interest? What if the person is fatigued, as a result of anemia, and this explains the lack of interest in activities? Guilt, my favorite criteria, since so much of guilt is unconscious, are we talking about conscious guilt? If so, very few people admit to this, particularly not int he first interview. Energy, see my comment on interest. Concentration, again, see my comment on interest. Appetite, decreased I can understand is a sign of mental dis-ease, but increased appetite is often a result of increased energy expenditure. Psychomotor changes, maybe a result of fatigue, or boredom, not necessarily depression. Sleep, same as appetite, in that it is often dependent on activity level.

So, am I dismissing our current diagnostic system? Yes and no. Symptoms must be taken in context. Context is understood through building a relationship where the patient increases trust, and therefore feels more free to display the context of his/her symptoms. A rush to judgment leads to a rush to medicate, leads to a patient not understanding his/her own mind. A delay in judgment could lead to needless suffering, but I would argue that the relationship building helps the suffering, so while I obtain a thorough history, I am also helping the patient symptomatically by providing a space for thought and reflection.

I want the patient’s history to become relevant again in psychiatry. This is a major reason I have this blog. I will repeat this point until my field changes its emphasis, or until I retire. I hope for the former.

Parents Worried About Their Six Year Old: Who Is The Patient?

“The fact that the parents bring in their child, that does not mean the child is the patient,” a trainee tells me with the wisdom of a more seasoned clinician. “Yes,” I enthusiastically agree. The patient’s opinion of the problem and the clinician’s opinion do not always agree, particularly in the field of child psychiatry where the “identified patient” may not be the one with psychological issues, but rather the target of family dysfunction. Herein lies the job of child psychiatrists, to discern the stated problem from the underlying problem. Johnnny, the fictional six-year old, may have behavior problems, but at the risk of offending my loyal reader Shelly, those behavior problems may not lie within Johnny, but rather they could stem from the discord between his parents. I reference Shelly here, as she is frequently concerned that I have a “blame the parents” approach to childhood assessment. Certainly, one size does not fit all, and sensitive parents can have children with severe behavior issues, yet, at the same time, there are times when severe aggression is a result of an environment which is chaotic and frustrating for the child. Johnny’s parents may be taken aback at the notion that his behavior is a result of insensitive parenting, and yet, this may be the message that the clinician needs to convey. What I am calling “insensitive parents” may then be so angry that their child is “misunderstood” that they will seek a professional who shares their point of view about their child. This inherent issue, that parents can only tolerate so much information about their parenting style, is the challenge of all child psychiatrists. Telling parents what they don’t want to hear is never easy, even if it means telling them that their child is normal and healthy. And one wonders why there is a shortage of child psychiatrists? Not.

Is It Severe ADHD or Childhoood Bipolar? The Case For A Longitudinal Assessment

Alan, now eleven, has seen me since he was four years old. Zane, his dad, was diagnosed with ADHD when he was thirty. Zane does well on stimulants, such that he reports that “they changed my life.” Theresa, Alan’s mom is a speech therapist, specializing in children with special needs. Beth, their younger child, has no issues that concern them. By contrast,seven years ago,  Zane and Theresa reported that Alan’s behavior was “really not normal.” They continued to state “his moods shift rapidly. “We cannot handle him. We think there is something seriously wrong with him. He gets upset at the slightest thing. He is not like the other kids. He throws chairs when he does not get his way. He cannot focus on “anything he has no interest in.  We know he is smart, but that does not seem to help him. His tantrums are simply out of control. Maybe he is bipolar or something.” Theresa tells me her frustrations with Alan, with tears in her eyes and a look of deep concern. “I work with special needs kids, but I have never seen anything like this,” she tells me.

I do my usual investigative work: I talk with Alan’s teachers. I see Alan myself. I gather more information from concerned relatives. Based on my review of the history and my observations of Alan, I conclude that he has ADHD and he needs a stimulant. We do a stimulant trial and Alan gets worse. “You see,” Theresa tells me, there is something else going on.” “Not necessarily,” I explain. The fact that he did not respond to stimulants may mean that his brain is too young to reap the benefit, so that maybe as his brain matures, he will be able to handle a stimulant better.” I explain. Theresa and Zane are not convinced.

  Fast forward five years, and we repeat a stimulant trial only this time, it is a remarkable success. Alan is doing better handling frustration and focusing at school. Fast forward two more years, and Alan is back to where he was at four, only now he is approaching puberty. Once again, Theresa and Zane believe that his behavior cannot be explained by ADHD alone. They are deeply concerned about  whether Alan has a chronic mental illness such as bipolar disorder, even though there is no known family history of this diagnosis. “I think he needs a higher dose of his stimulants. I also think that puberty has exacerbated his mental state, such that with time, his brain will mature and his frustration tolerance will improve.” I explain, again, not convinced that his low frustration tolerance is related to childhood bipolar disorder.

  Alan only tantrums when he does not get his way; when he is not the center of attention. Theresa and Zane are admirable parents, but they need to understand that raising Alan is more demanding because of the severity of Alan’s ADHD. They need to work harder at  providing consistency and structure. We have talked about these parenting skills and they are on board, but still skeptical of Alan’s future mental functioning. “I think time is going to be on our side,” I say, explaining the wonders of maturation. “Medication will also help,” I say, agreeing with them, that parenting alone is insufficient to deal with the severity of Alan’s behavior.

Theresa and Zane, after much discussion, feel a bit relieved that we are still dealing with the same issues that we were dealing with seven years ago. Alan too, looks forward to increasing his medication, as he says “I don’t like that I behave this way. I really don’t,” with shocking insight into his difficulties. There is hope in the air. We will see how it goes.