Addressing The Mount Olimpus - Psychiatricanswers

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Addressing the Mount Olympus

This is letter was sent to the Chief of Psychiatry of a prestigious Ivy League hospital with zero expectation of response. Just for the record:

August 4, 2012
Distinguished Chairman:
I would like to present you with an idea that could have a significant impact in the practice of psychiatry.  I say so because your university is considered one of the most trusted, worldwide source of scientific information. So much that I think of what it is teaches at your institution as the equivalent to a Supreme Court decision: it becomes the Law of the Land.
As a practical example I can tell you that colleague said, during a gathering earlier this year, that about 55% of bipolar patients also have ADHD. When I expressed my doubts on such a high co-morbidity and the doctor dismissed my opinion with these words: “keep in mind that I got this information from the last psychopharmacology update that I attended in …..”
From this perspective I believe that it could be scientifically productive to have a “lunch/discussion" between 5 of your doctors and this writer on several issues that were raised as part of the lectures on Autism, Treatment of ADHD, Substance Abuse and ADHD and the PTSD treatment. My idea is to bring food and drinks to your office if we could have you as a moderator.
The points that I would like to argue with these respected members of your faculty mentioned above are the following:

1. DSM-IV clearly establishes that ADHD cannot be diagnosed when the symptoms are “better accounted by a PDD (see enclosed criteria).  I found interesting that Dr. xxxx emphasizes the important of following DSM criteria (during the Q&A segment) but he seems to forget about those guidelines when he (and Dr. xxxx) accepts the ADHD/Autism Spectrum Disorders co-morbidity.  I must state at this point that I am aware that about 95% of American psychiatrists endorse such co-existence as well as the validity of what I consider diagnostic artifacts: ODD and Conduct Disorder. (Do you remember the 2002’s headline “Risperdal effective treatment for CD”? Has anybody gone back and revised that data? I would not be surprise if most of the subject in that Canadian study now have a real diagnosis).

2. If irritability and repetitive behaviors (obsessions/compulsions) are improved by a dopamine blocking agent how can they explain that similar outcome could happen with dopaminergic drugs?  I believe that those patients with “autism spectrum disorder” that showed a decrease in the targeted symptoms have conditions that do not fall in the OCD spectrum, as described by Dr. Eric Hollander.

3. In the treatment of PTSD I have gathered solid statistic evidence to demonstrate that SSRIs are detrimental to those patients with nightmares (dreams become more vivid) and that co-morbid bipolarity converts to either rapid cycling or dysphoric mania.

4. The importance of genetic inheritance should be given more relevance as a diagnostic tool. I believe that looking at a child’s symptoms as if they occur in a vacuum runs counter to the classic teachings of the pioneers of C & A psychiatry as a scientific field: the identified patient should be understood in the context of the family dynamics.  In other words, the child of a drunken father that exhibits bouts of rage should be analyzed with a broad spectrum of possibilities in mind, including one that I consider highly relevant: maybe that father has a mental illness and chances are that his child “got his genes,” as I hear from many mothers.

5. There is no such thing as “ADHD symptoms.” We should remember that as physicians we don’t call a RLQ abdominal pain an “appendicitis symptom” even though it is a clue of this ailment. Still, in one of the lectures mentioned above the assertion “ADHD symptoms” was cited 5 times in less than 2 minutes.  It goes without saying that restlessness, impulsivity, poor attention span, etc. are seem in other psychiatric conditions and that, as DMS states “ADHD should not be diagnosed when the symptoms can be explained by the presence of…”

6. I want to present your team with this question: Would any of you seek medical help from a neurologist with a reputation of diagnosing with Multiple Sclerosis 90% of his or her patients? I suspect that a professional with this kind of diagnostic prevalence will be reported to the Board of Medicine but, curiously, in psychiatry doctors and psychotherapists do it without any questioning from their colleagues.  I mention them because they are professionals in primary care which is a very different scenario to the setting of a Dr. xxxx or Dr. xxxx who (I believe) evaluate patients as consultants of colleagues that have questions regarding Dx and treatment.

7. Another question could be this one: How is it that a misdiagnosed patient with racing thoughts, impulsive/aggressive behavior that displays a worsening of symptoms (labeled as oppositional-defiant) after a trial with amphetamines can control an out-of control mind with Cognitive Behavioral Therapy?

Inspired by the words of the brilliant English thinker Francis Galton who said “it is truly absurd to see how plastic a limited number of observations become, in the hand of men with preconceived ideas” my goal is to have an intellectual discussion within the frame of the respect I have for the brilliant minds that integrate your staff.  By the way, as History teaches great thinker can also be wrong.  I could mention the case of a patient that came from a Midwest state for a Second Opinion while in treatment provided by the Director of Training at a respected medical school.  You could see the posting her mother placed on the ADHD forum, mentioning my name and giving testimony of the remarkable improvement her son had just by d/c the amphetamine he was taking, in addition to a mood stabilizer that his doctor prescribed for his bipolar disorder.
In fact, I began to think to write a letter like this on a day that we all remember, 9-11-2001.  A few minutes before the first airplane hit the tower I finished evaluating a 50 lbs. child that was taking 70 mg of methylphenidate while displaying very aggressive behavior and having A.H.  I thought “this should not be happening at a Yale University’s clinic,” where he was in treatment before moving to Florida.
I hope this letter could reach your hands and that you will give a serious consideration to my proposal despite the fact that, on the surface, it could sound like an impossible dream.

Manuel Mota-Castillo, M.D.
Lake Mary, Florida

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