Psychiatric Arrogance and Ignorance - from the horse's mouth

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Tonight I read a book written by a psychiatrist called "You Need Help". It is repugnant to me in its paternalism, patronisation, platitudinous arrogance and ignorance. That was bad enough. But the worst part was a case history he relates in it, and I am going to make the effort to produce it in full here. The book (please note this) was written as late as 2012.

Here is the psychiatrist's verbatim summary of his diagnosis of a patient, Carl, in the author's own words in full:

Carl, a forty-five year old man, came to get psychiatric help for depression. He looked a mess: dilapidated and in need of a bath and shave. He was unable to sustain eye contact and stared out of a window. He spoke in a monotone, with almost no emotional modulation. He described his anxiety and depression. He lived alone, was unemployed, and had no friends. As I asked him to tell me about his life, he told me he was a "world famous scientist" who was a theoretical physicist, with solo publications (no co-authors, the most difficult kind of paper to get published) in some of the most prestigious journals in the world. He named an incredibly impressive list for me. He said he had won many scientific awards. In fact, he explained, "I was on the shortlist for the Nobel Prize" at one point. From his appearance and his speech, he really did appear to have a major mental illness like schizophrenia and these grandiose claims seemed to go along with the delusional psychotic ideas that are typical of such illnesses.

At the end of the evaluation, I agreed to see him again and asked him to sign a release to let me speak to his parents who lived in San Francisco. He readily agreed. I called them a few days later and told them their son Carl had come to see me in Baltimore, and I wanted to ask them some questions about how long he had been having delusions of being a famous scientist. Before I could ask the question, his mother said "Poor Carl. Did you know he was a full professor, a famous scientist, won many awards, and published solo papers in the most prestigious journals for many years? He was even considered for the Nobel Prize at one point". As improbable as Carl's story seemed, it turned out to be all true; his parents were present at every step (and I got copies of his scientific papers to satisfy myself). This man was not suffering from a psychosis, but from a terrible depression that had ruined his career. He was not schizophrenic. Had I not gotten to anyone other than the patient, I would have misdiagnosed him."

..

I found myself literally shaking with anger after reading this. I was able to locate an email for this psychiatrist, and sent him the following message:

May 12
I was deeply distressed to read your account of "Carl".

Your patient, in 2012, presented as someone that was very probably suffering not from schizophrenia (as you so arrogantly assumed, it seems, invalidating his life experiences and self report) nor depression as a primary state.

I believe you owe him a huge apology. Why did you miss such a clear example of the way the Asperger's Syndrome can present? How could you not know that depression was a comorbid that was the result, not the cause, of the marginalisation of a man so clearly on the spectrum?

I feel terribly worried for anyone on the spectrum who is seen and evaluated by you. You missed it completely, while concluding (and congratulating yourself) on finally reaching the 'right' diagnosis, which was wrong.

You did this man a tremendous dis-service. It was horrifying to read. It was heartbreaking to read.

I would not be surprised if he later became suicidal due to your incompetence. I am sorry to sound harsh, though the implications of your ignorance are really alarming to me.

This man did indeed "need help", and I am sad that he sought it from you, because you compounded his plight by missing the core issue.

I hope I never read anything like that again. It made me feel physically sick.

Yours sincerely
A concerned psychologist

..

I fear for undiagnosed and unsuspecting AS people who seek help from psychiatrists. The tunnel vision of psychiatrists can be so dangerous, and destructive, and the damage they do is unmonitored and usually never revealed at all.

One would hope that the clinician found your letter instructive, rather than a blow to his/her ego.

Clinicians adhere to preconceived notions like they are Super Glue. And there is a general reluctance to listen to input from “laypeople.”

What's worse is that this was so easily verifiable,
scholar.google.com
tappity tappity and it would be verified in 3 seconds flat.

I'm not getting the outrage. Some guy who is like a transient making very grandiose claims, would be far more likely to be someone with a psychosis (aspergers or not). And I get the idea it's a fictional account to make a point of not jumping to conclusions despite what seems to be compelling evidence. But of course I haven't seen the whole book.

Why didn't he look this guy up? Surely his name would be on the internet if he were famous and his writings too. Now I wonder who this Carl is. And not every pathological liar is a schizophrenic. Not saying the patient was lying, just saying just because someone is lying doesn't mean they are a schizophrenic, there is such thing as being a pathological liar. There are different reasons why someone would make false claims.

It is best to see a psychologist, not a psychiatrist because psychiatrists are trained to see mental illness and prescribe drugs. They often miss all sorts of developmental, neurological, and genetic conditions.

Agreed.

The profession of psychiatry has gone by the wayside, it seems.

All they seem to do nowadays...is to prescribe drugs. No therapy at all!

But you can't really assume that carl had Asperger's syndrome, either.
Isn't that repeating exactly what the psychiatrist did at first?
Personally, I think it's great that he sought out further information in this case, not all would do that.

Unless they are autism specialists.

Get things straight please.

To "lie" is to intentionally tell a falsehood. The doctor never said he thought the guy was "lying", nor did the doc say he equated lying with psychosis.

The doc said that he, the doc, thought that the patient was "delusional" (which IS a symptom of pyschosis). That the guy sincerely believed that he was this high falutin scientist,. But the doc assumed that those beliefs couldn't be true, but not that they were "lies" , but that they were delusions (the patient thought that they were the truth, but were not). And of course it turned out that he really WAS a high falutin scientist who was neither lying nor delusional.

I will always wonder what happened to that patient, and if he shared the same fate as Will Moore, another professor very likely on the spectrum who killed himself, leaving a long public note explaining that he couldn't bear the pain of being misunderstood anymore.

I can't know for sure that either were AS. From the descriptions of both, the balance of probability leans strongly that way, and in the case of the physicist, the signs were there and should have, could have, been explored by a competent practitioner, one with more knowledge and respect, and less arrogance.

Psychiatry tends to attract, as a profession, certain kinds of personalities (in the ones I have met over the years, there are two, one benign, and one quite dangerous, the latter tainted with narcissism and a self-certainty that manifests in an extreme arrogance). Any profession or career path that confers tremendous power over others carries the risk of attracting the latter type.

This man (the theoretical physicist) did need help. But help seeking can be a perilous undertaking (which is why I am currently looking at suicide support services and their ways of failing AS people). Help can be the "sunny smiling face" of control, and serve the ego of the helper. What a tragedy that Carl had the misfortune to seek it where he did. I hope he survived. I wonder what Tony Attwood would think of the psychiatrist's account, and if by some tiny chance he ever reads this (very unlikely) I would so much appreciate his thoughts on it.

Of course Raleigh, I can't be sure; you look for evidence and the balance of probabilities, but you look for it carefully, knowing the whole range of possibilities. Clients have a right to expect competence in practitioners, and I think this one failed that test, you may disagree. But that's ok.

There is an underlying theme in the psychiatrist's account that mental illness and very high academic achievement are mutually exclusive. They aren't, and the assumption is a misguided and ignorant one, a prejudice that compounded the danger of for his patient. How many other AS people did this man harm, I wonder, before and after Carl.

I am with B19 on this one. In my experience, some of the most arrogant and ignorant people are psychiatrists. Not all, of course. And the damage they do is beyond tragic. I wonder, B19, if you will get a response from him.

Reminds me in The Sixth Sense when one of Malcolm Crowe's patients comes back and says he failed him because he had given him a misdiagnoses when in fact he had a gift of seeing dead people. Then he shoots him and himself.

They didn't even evaluate the man, all they did was jump to conclusions

I'm having real trouble understanding the issue here.

The psychiatrist automatically didn't believe the man when he said he was a famous scientist and won so many awards and wrote several papers and published them. So he assumed he was delusional. Why did he assume delusion when he could have assumed other things? He could have assumed narcissism, he could have assumed pathological lying, he could have assumed the man is so depressed and has so much low self esteem he has created a fantasy world for himself and now believes his own lie.

He could have simply looked him up online. Famous people will be online. I am only assuming Carl is a psyodium (sorry, don't remember the word) name he was using. Carl was lucky he was still in contact with his family and had a supportive family or otherwise he would have gotten misdiagnosed as schizophrenic because the doctor couldn't be bothered to use Google.