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Solving the Puzzle

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The Anatomy of a Psychiatric Consult

Steven Dubovsky

For many therapists, an air of mystery surrounds the role of psychopharmacology in mental health treatment. It seems like a parallel universe, standing apart from the usual concerns of psychotherapeutic encounters. In the interview below, psychiatrist Steven Dubovsky—author of Clinical Guide to Psychotropic Medications and chair at the University of Buffalo School of Medicine and Biomedical Sciences—offers a step-by-step tour of the complexities of the psychiatric consultation while exploring the overlap between psychopharmacology and psychotherapy.

What’s the process you go through when a therapist sends you a patient for a consultation?

Steven Dubovsky: For any condition, I go through an algorithm of the most likely causes of treatment being stuck. About 40 percent of the time, it’s because the patient’s diagnosis is incorrect, but sometimes people actually try to hang on to their diagnosis, especially if it sounds exotic. Some people say things like “I’m a rapid-cycling bipolar with mixed and psychotic features” with glowing pride, as if they’d happily write it on a name tag. Or, as if the consultation were some kind of show and tell, they might say, “I’ve got multiple personality disorder. Do you want to see some of my personalities?”

Since I always tell people that they can bring along anyone they want for the initial consultation, when I decide that the diagnosis isn’t correct, which I often do, I’ll ask the other person what he or she thinks. This is useful because a lot of times when a patient says one thing, his spouse will be sitting there shaking her head. For example, I might ask the patient, “Are you often irritable at home?” And he’ll say, “No, that’s the one thing I’m not. I’m not irritable.” But the spouse will say, “Not irritable? Didn’t you throw a vase at me last night?” Of course, the patient may have genuinely forgotten about throwing the vase. Part of that is because recall is state dependent. At that moment in my office, the patient is in a different emotional state from when he threw the vase.

What role does diagnosis play in your assessment procedure?

Dubovsky: Well, the correct diagnosis should inform, at least in general, what the treatment might be. Of course, this is a tricky issue because DSM diagnoses, by and large, aren’t that reliable and have questionable validity in predicting treatment response. But where diagnosis really changes your treatment is with people with complaints of depression or attention deficit disorder, or a personality disorder with a lot of affective lability. For example, when someone has an underlying bipolar mood disorder, a prescription of antidepressants often makes the mood disorder worse. In that case, you’re going to take a step back and change the medications completely.

As someone who’s regularly in the role of being a troubleshooter when drug treatment goes off course, what are the two or three factors you usually find are most responsible?

Dubovsky: Common causes of refractory conditions in the cases I see are undiagnosed bipolar mood disorders, medical conditions that are aggravating or even causing the supposed psychiatric illness, and failure to recognize the effect of substance abuse on the patient’s symptoms. But the most common are probably noncompliance, failure to recognize underlying family problems, and clinicians getting too focused on symptoms to get the big picture of the patient’s life.

Again and again in the cases referred to me, I discover that even when the treatment approach being taken isn’t working, the therapist has continued to do more of it. So if you’re talking about the patient’s past and the patient is getting worse, some therapists respond by saying, “We just haven’t resolved this yet. We’ve got to work harder on it.” Or even as the patient has become increasingly overstimulated and disorganized, the therapist might say, “This is proof that we’ve touched a nerve and are finally getting somewhere.” Or the patient says, “I can’t stand this. I feel worse every time I come here.” And the therapist replies, “You have to feel worse in order to feel better.” I remember one unhappy patient who told his therapist, “Is there a law against feeling better? What’s the matter with that?”

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