November 16, 2006

The Ten Biggest Mistakes Psychiatrists Make

Long but necessary.

 

 


1. Talk too much

 
It’s not a conversation, and it’s not a debate.  You are either treating their symptoms with medication, or guiding them to “treat” their own symptoms.  Neither requires much talking.

If the psychiatrist says more words than the patient, then the psychiatrist is the patient.

Many psychiatrists talk because they feel powerless.  The patient is in distress.  How can the session be worth the money unless they get some thing?  A prescription is good, but what else—what now?  So the psychiatrist thinks they need to say something, to appear as though you are giving something to the patient.  The worse the situation is, the more the psychiatrist talks.  You’re talking to make yourself feel better, to justify your value as a psychiatrist.  Don’t do this.  It’s not help.  

And empathize, don’t sympathize.  I cringe whenever I see a psychiatrist on the first visit  try to sound genuine while they affect a sad and shocked voice, lean forward, grab a box of tissues, “oh my God, I’m so sorry, that’s terrible!”  It’s fake, which makes it annoying, but it’s patronizing, which makes it countertherapeutic.  A psychiatrist cannot sympathize—did the same thing happen to you?.  What they need to do is empathize, to understand the feelings, to appreciate them—not to share them.  Plus, you don’t know what the situation means to the patient.  Maybe they’re secretly happy (and guilty about it), and now that you’ve confirmed that it’s “terrible,” they’ll never admit to you or themselves they’re happy about it.  Simply saying, “I’m sorry.  Can you tell me more about…” is all that’s necessary. 

And enough with the tissues.  If you stalled the interview to go get them a box of tissues, you have failed, you changed the energy of a key moment.  And you did this—let’s be honest—not because they needed tissues, but because it took some pressure off the moment and allowed you to give them something.  Leave tissues by the patient chair from the beginning, and focus on what you’re doing.

I had a great mentor who taught me to begin the first session with the words, “Where would you like to begin?”  And then to shut up.  Great advice.

 
 
2. Take too much history

This is going to be controversial.  I can hear academics seizing.

I know psychiatrists are taught that careful, meticulous history taking is the cornerstone of good care.  Well, it’s not.

Every session should be about the patient, not about you.   You’re supposed to help them, not understand them.  The two may go together, but they might not.    It is possible for you to help without understanding, but it is not acceptable for you to understand without helping.  You’re not CSI, you’re not Batman, you’re not trying to solve a mystery or make some aha! discovery.  They’re telling you what’s wrong.  Just listen.   Taking a detailed history may seem like a good idea, but many times it is masturbation, it contributes nothing to the patient’s well being, it only makes us feel thorough.  As in: well, I can’t do much for him, but I got a really good history.  Remember, it’s not about you, it’s about them.  It may seem as if a strong family history of bipolar disorder is important information, but it isn’t.  I know, bipolar runs in families and blah blah blah. You couldn’t tell they were bipolar before you learned their family history?  And how do you know the family’s diagnosis was correct, so that you can rely on it to make your diagnosis?


I’m not saying don’t get the information.  I am saying devoting the first one or two sessions exclusively to this gains the patient nothing.  Everything from the moment they walk through the door should be about their service.  Forget about the notes, especially outpatient notes.  Worry about the patient, the notes should come second.

Are you proud of your notes because they contain so much detailed patient information?  You need to think about this.  Did you break eye contact to write, “sad over husband’s loss?”  Then you missed the moment.  Just listen—write your notes after the session.  And if I see one more  psychiatrist with a note pad playing stenographer I am going to punch him in the neck.

 
 
3. Ignore smoking cessation

or at least make it a secondary outcome.  Also applies to soda/juice/calorie reduction. 

This may seem trivial.  It’s not—after the treatment of the initial presenting acute symptoms and treating drug and alcohol abuse, this is more important than almost anything in psychiatry.  The logic is as follows: 

1. Smoking is obviously and severely detrimental to one’s health, arguably more damaging than hypertension and depression combined.  Its effect on life expectancy rivals, well, arsenic.

2.  It is an addiction, so it is psychiatry’s business. 

3.  It is highly comorbid with psychiatric disorders, and may be a relative symptom of them.  (For example: half of all people who commit suicide smoke.) 

4.  Smoking itself has a significant impact on other medications (e.g. did you know it reduces Haldol by half?)

5.  What the hell else are you doing with the session?   Especially in the “maintenance” phase of psychiatric treatment (where symptoms are relatively controlled, etc). 

All of this applies equally to soda consumption or even diet in general.  Drinking 2 liters of soda a day may not seem like a psychiatric issue, but most of the medications used have the propensity to increase appetite, and excess eating, smoking, soda drinking are hardly psychologically meaningless behaviors.  If your psychiatrist asks you to keep a mood chart or teaches you about “serotonin dysfunction,” but doesn’t tell you to quit smoking, run.  He has missed the forest for the trees.

 

4. Blame lawyers/insurance companies/Big Pharma

 
In order to understand why this is such a popular mistake among psychiatrists (all doctors, actually) it’s useful to identify when psychiatrists do this.  There are two specific times.  The first is when psychiatrists seek to justify doing, or not doing, some clinical maneuver, as in, “I can’t discharge him from the emergency room, even though I don’t really believe he is suicidal, I think he is lying simply to get hospitalized-- but I don’t want to get sued.”  The second time is when psychiatrists seek to explain a reduction in income, as in, “The insurance company only pays so much for a visit, so now I do only med checks.” 

What is striking about these justifications is that they almost never relate to the specific problem at hand, they are scapegoats for some general anger about the difficulty of practice.  For example, in the example of the malingering emergency room patient, discharging him has no increased risk of legal liability because if the patient is, in fact, malingering, then he will not kill himself.  The operational issue here is not one of increased legal liability, but whether a physician can detect malingering.  This has nothing to do with lawyers. 

In the second example, while it is certainly true that the insurance company has set reimbursement rates, psychiatrists have not explored their responsibility in this.  They have not, in any scientific, economic, and most importantly policy way, justified the necessity for a different (read: higher) reimbursement scheme.  Consider psychiatrists’ attitudes towards psychologists acquiring prescribing privileges.  It seems obvious that psychologists shouldn’t prescribe medications, but why not, exactly?  To say that psychiatrists are trained in medicine and better understand drug-drug interactions, dosing, and toxicities presupposes that the average psychiatrist actually does know about drug-drug interactions, dosing and toxicities.  Really?  What’s the interaction between Prozac and hydralazine?  Don’t know?  Then why should psychologists know?  And if you can look it up, so can they, etc, etc.  Also, using this reasoning could backfire, as it can justify an insurance company refusing to pay for a psychiatric med check since the service could be performed by a primary care doctor (who will also handle everything else for the same low price.)  Again, it is easy to complain, but it is on psychiatrists to explain, rationally, why it should not be.

Consider the common complaint that each insurance company has its own formulary, requiring doctors to prescribe alternatives, generics, or submit prior authorization requests.  This is taken as bureaucratic interference of patient care.  However, in the majority of the cases these restrictions are economically and clinically valid.  No logic, let alone evidence, exists for prescribing two antipsychotics simultaneously.  So why should the insurance allow it?  Similarly, an insurance company should be allowed to approve drugs based on cost, because unless one can show that, for example, two SSRIs do not have the same general efficacy or tolerability across a population, than an insurance company cannot be reasonably obligated to provide both, especially if it can contract to receive one of the SSRIs at a cheaper cost.  To be clear: it may, in fact, be true that (for example) two antipsychotics are better than one.  But the burden of responsibility is on psychiatrists to show that this (or any clinical) maneuver is necessary, and not on the insurance companies to simply trust that doctors know best, because they have shown repeatedly that they do not.

Blaming lawyers has almost become a sport.  It is certainly true that uncapped awards for damages hurts everyone (except lawyers.)  However, lawyers are good at picking  malpractice cases, not at inventing them.  Consider informed consent: if one prescribes valproate for maintenance, one must not only discuss the side effects, but also the alternatives to treatment-- especially when the alternatives to Depakote (a drug which has neither approval for maintenance nor rigorous data backing it) do have such approval and data  (consider lithium, Zyprexa, Lamictal, etc.)  To prescribe Depakote because it is at the top of an algorithm or in the “guidelines”, or because “that is my practice” and not because of a reasoned analysis of the individual merits of the case, is at minimum not thoughtful practice.  A similar example is psychiatry’s current obsession with antipsychotic induced diabetes.  Assume that Geodon does indeed have a much lower risk of diabetes than Zyprexa; is a psychiatrist any less liable if the diabetes is induced by Geodon and not Zyprexa?  No.  You don’t get sued for using Zyprexa.  You get sued for causing diabetes and never picking it up.

To state explicitly what seems the most obvious point of all: if a medication causes a side effect, and you catch it, there’s no lawsuit, because there’s no damage.

The above examples come from misunderstanding the available scientific literature, or not knowing it at all.  Oddly, if a lawyer does not research the current state of case law and statutes before answering any legal question, it is legal malpractice.  But doctors practicing medicine are not required to review current journal articles on any medical condition. 

Pharma is the most maligned of all.  On the one hand doctors resent the intrusion of the industry on their practice; on the other hand, industry is the primary—often only--  ongoing educational source for doctors, whether they believe this or not.  Drug reps, throwaway journals and supplements, “drug dinners” and almost all CMEs (yes, CMEs  too, stop lying) are all industry sponsored educational processes which are the de facto continuing education of most psychiatrists.   Oh, right, right--  doctors learn by regularly reading numerous journals carefully and thoroughly.  Ok--ask them to name one article in the most recent issue of the American Journal of Psychiatry.  Not the results of the study; just the title.

One may want to ask why the FDA feels it necessary to hold pharmaceutical reps to extremely strict standards: they cannot mislead, they cannot speak off label, they must discuss side effects and toxicities, and they cannot use any promotional material that was not reviewed by the FDA.  Used car salesmen are not held to any standards, and they sell to idiots.  No one needs to tell you the rate of blowouts on a Firestone tire.  Why would doctors—the most educated consumer group in existence—need protection from salespeople?  Shouldn’t doctors, ultimately, know more about the medications than the sales reps do?  Unless…

The sad truth is that the state of psychiatry is the fault of psychiatrists, who have failed to take full responsibility for their own education and practice.  To blame anyone else at this stage is remarkably disingenuous.

 

5. Become social policy analysts

 
Remember how in May, 2005, the American Psychiatric Association endorsed same sex marriage?   And you applauded the moral fortitude and progressive instinct of this august body?  Well, instead of debating whether there should or should not be same-sex marriage, perhaps we should ask what modern psychiatry could possibly contribute to this discussion. The answer is nothing.

You can't get away with pat answers, such as psychiatrists see the psychiatric ramifications of discrimination or being unable to marry. There are psychiatric ramifications of bankruptcy, and war, but no one felt compelled to write a policy statement on it (and thank God.)

And no, there isn't a difference between bankruptcy and gay marriage-- not to psychiatry. That's the point. These are social problems about which modern psychiatry is definitionally ignorant. The APA did not endorse polygamy. What's the difference? If homosexuality is not a psychiatric disorder, than there is no more reason to be more for or against it than there is for any other kind of marriage. The APA is no better suited to answering these questions than, say, the NFL.

What if the NFL came out against antidepressants in children? This is a perfectly valid analogy, because neither the NFL nor psychiatry have special knowledge that make their statements anything more than opinions. What do psychiatrists know about same-sex marriage that the quarterback for the Patriots doesn’t?  Don’t laugh—I’m serious. What’s the answer?

Medicine, or the APA, can legitimately express a policy only if  the policy was grounded in science or logic. Perhaps the APA cares to release this intriguing scientific data?  (While it is at it, perhaps it can also release the data supporting the use of half of the medications currently favored by APA Guidelines?)  But this seems pretty much business as usual for the APA. Rather than work on its own serious failings, it involves itself in social policy.

“Modern” (read: pharmacological) psychiatry is obsessed with reinventing itself as a biological and scientific discipline. Well, if it wants to be a science, it better start acting like one.

The FDA effectively killed Vioxx, and not a peep was heard from the APA about the dangers of letting the government regulate their practice. You can say Vioxx has little to do with psychiatry, but it’s still a lot more than gay marriage.

Determining what is true and what is not, through serious and often disconcerting scientific enquiry, is very difficult. It is much easier to involve oneself in matters of opinion and debate, in activism, because it is both immediately rewarding and it is easy. It’s hard to measure things in psychiatry, and when it is possible the results are often disappointing. So it busies itself with matters of conviction because it feels some responsibility to have convictions. It doesn't. It has a responsibility to the truth, and if it doesn't want to invest any energy in that pursuit, it is on them. But don't mask it with whimsy and dilettantism.

I should point out that gays, far from being pleased with the APA’s stand, should actually be horrified.  Do you-- does anyone-- want social policy suggested by psychiatrists? Think long and hard.

Imagine the outrage if the APA had come out against gay marriage, or for the war in Iraq. There would be battalions of people saying, "well, what the hell do psychiatrists know about war in Iraq? Who the hell do they think they are telling gays not to get married?" There is no protection in being confident of the rightness of your current position, as history is loaded with examples of how terribly bad doctors are at determining what is right and what is wrong. Not long ago homosexuality was considered a disease. See?  The Tuskegee experiments were endorsed by the AMA, and the AMA gave its endorsement,  after ethics concerns were raised by Peter Buxtun. Remember that?  How about the speech to the1941 APA meeting, and the 1942 issue of the American Journal of Psychiatry in which euthanizing the “feebleminded” (IQ<65) sounded like a good idea?  

Psychiatry would do well to remember Wittgenstein TLP 7: Whereof one cannot speak, thereof one must be silent.

6. Don’t refer to therapy.

Psychopharmacology without therapy is treating an infection with Tylenol.

Medications do not cure a psychiatric disease; we’re not even sure what the disease actually is.   What they can do is reduce symptoms, give you strength—so that you can learn new behaviors.  That’s the point of medications.  Treating depression with an antidepressant is not the solution; it’s the preliminary step in allowing you to figure out how to handle depression later on.  The adaptation, the adjustment, the physical altering of brain functioning is done by new learning, often this is therapy (though it doesn’t have to be.)  I’m not saying therapy is that great, or necessary, either.  I’m simply saying that trying to improve a person’s long term status using medications alone without some sort of education and training is a waste of time.  It is maybe the most profound disservice of all to tell a patient that their depressive or bipolar symptoms are the result of biology or chemical imbalances and thus absolve them of the responsibility of learning new ways of interpreting and coping with their environment.

 

7. Don’t think strategically.

Psychiatry is fun, I’m sure, but it doesn’t help anybody when the patient refuses to play.   Psychiatry telling us opiate abuse is a heritable disorder related to polymorphisms in dopamine receptors doesn’t stop your kid from stealing your money to buy smack.  See?  Sometimes you have to hide your wallet.

What is the goal? What do you have to do to achieve that goal? Sometimes you have to look beyond the DSM.

Do what you have to do.  When a person needs treatment but is refusing it, neither the law nor psychiatry can help them.  I can’t force someone into treatment.  But you can.  Take drug abuse: in my experience, the only way to get someone to (albeit reluctantly) accept treatment is a large scale intervention.  10 people, minimum, in a cramped room with the future patient trapped as far form the door as possible, all ten  in energetic agreement that the person needs to get help-- now.  Not tomorrow morning.  Immediately.  You’ve already packed his bags.   This isn’t a five minute pep-talk—take the whole day off, you’re going to be there a while.  Also, a psychiatrist cannot do this for you, he shouldn’t even be there, because no one ever listens to neutral third parties, much less psychiatrists. (And I'll just say it: you probably don't want a psychiatrist there in case you...have to take things… to the next level...) It has to be ten highly motivated, concerned people.  If you are not motivated enough to stage this uncomfortable intervention, I assure you he won’t be motivated to go.  This is the kind of thing a psychiatrist should be telling you, not trying to sell you on Suboxone.  Nobody likes confrontation or to be confronted.  Ten people.  Minimum.  Sure, you are partly guilting them into treatment, partly coercing.  But getting them into treatment in this way is better than not getting them into treatment in a nicer way.  Psychiatry is war.

 
Sometimes people don’t need to know.  If a person’s life is changed on medication, it may be okay not to tell them all the side effects.  I know, lawyers are standing by (see # (blame lawyers),  but again, it’s strategy, and I think reasonable people (i.e. juries) will understand what you were doing.  If lithium keeps the person from slitting their own throat, it’s okay to skip the part about how it can hurt your thyroid.  It doesn’t exempt the doctor from checking for it, mind you.  In these tricky situations, a) you have to be sure this medication is absolutely vital; b) recruit as many people as possible into the therapeutic umbrella.  Tell the wife about the side effect; tell family what to watch out for.  And monitor.  There’s even a technical term for this therapeutic privilege, but I can’t remember what it was.

 
Save the environment.  Here’s an all too common scenario involving no strategic thinking:  Your adult child is living at home, no job, sporadic drug use, involved in an abusive relationship, frequent quasi-suicidal acts, etc.  You’ve tried everything, nothing has worked.  You don’t know what to do.  You’re afraid to kick them out because  they can’t manage on their own, you’re afraid they’d sink deeper into drugs/depression/etc;  but on the other hand you have other kids you have to worry about, a finite supply of money, etc, etc. You’re paralyzed.

Here’s a question you might not have thought about: what happens to the kid when you die? They are suddenly going to be without support, suddenly without money, suddenly without resources.  Will they simply manipulate your spouse into getting their needs met?  Or worse, go somewhere else?  Is that what you want?  Plan today, now, for this eventuality.  Maybe that means setting up a trust with a finite monthly payout only if they are living on their own and have a paycheck.  Or only if they are seeing a therapist once a week.  Or give clean urines.  “What is this, probation?”  Actually, that’s exactly what it is. 

You have to save the environment you are in before you can help the other person.  That means protecting your wife and other kids, and their physical assets. It means protecting your marriage.   It may seem cold to worry about money when your kid’s on heroin, but I assure you that this is the most important thing you can do if the kid won’t get help.  Ripping apart your marriage over this benefits no one, absolutely no one. So yes, it may mean kicking them out of the house, cutting them off.  It also means doing an intervention.  It means holding your breath that that phone is going to ring in the middle of the night and it’s going to be the police.  But letting them eat, sleep, and watch TV in your house while their chaos continues does not lessen the risk of receiving that phone call.

It’s called enabling.  Don’t do it.  And a psychiatrist should be telling you this, not trying to give you Celexa to help you cope with it. 

8. Polypharmacy

Polypharmacy isn't just common-- it's the codified standard.  When two psychiatrists discuss a patient, inevitably one of them will say these four words: “You should consider adding…”

The paradigm is that if you fail a medication, you must be so sick that you need a second medication.  

It's a useful paradigm; and by useful, of course, I mean wrong.  Here's an alternative paradigm: maybe if the medication didn't work, you should try a different one?

Polypharmacy would be ok if there was at least some data justifying it.  But there isn't.  I know, controversial.  Look it up.

Consider antipsychotics: if anyone can provide the logic-- not data, simply the logic-- for using two simultaneously, I'd love to hear it.  Antipsychotics work by blocking dopamine receptors, of which there are supposedly a finite number.  If one antipsychotic blocks most of them, where is the other supposed to go?  Why couldn't you simply increase the dose of the first?  And if side effects prevent this increase, why wouldn't you just switch to the second medication? 

Same with antidepressants: Zoloft and Prozac are SSRIs, they target the exact same molecule, which is again finite in number.  If most are blocked by one drug, where does the second go?  Why are you offended that Medicaid doesn't let you prescribe two at the same time?

So you say: well, what about mixing two drugs of differing pharmacologies, like Zoloft (serotonin) and Wellbutrin (dopamine/norepinephrine)?  At least there is logic to this one, but--surprise- no evidence.  It may seem as though Zoloft + Wellbutrin, or Depakote + an antipsychotic, etc is better than one alone, but they're not.    But here’s the point: even if it were true, so what?  How do you know it’s necessary?  Shouldn't prudence and common sense and fiscal responsibility and the cramp in your writing hand require you to at least try monotherapy a few times?  Twice, at least?  Because I can't prove two drugs are better than one, but I can prove they are twice as toxic and twice as expensive.

Polypharmacy is bastard child of the theory of maintenance treatment.  If it took three medications to get you feeling better, then you need to continue these three medications in order to stay stable.  Going off your medications results in disaster.

First of all, no.  Secondly, take the example of mania.  If you're manic, and it took three medications to bring the mania down, does that mean you need those three for the rest of your life?  Because if so, what do you do the next time you get manic?  Add a fourth?  Don’t you get used to medications?  Does tolerance not occur?  Upregulation and all that? You see the problem-- maintenance begats polypharmacy.  Also, medications have side effects, and so medications are given for the side effects of the other

medications, ad nauseum.  At some point (four medications?) the symptoms you are seeing cannot be reliably ascribed to the disorder rather than the medications themselves.  The patient is buried.  The treatment now becomes getting them off these medications.

Again: it may be true that an individual person needs several medications.  But you can't make polypharmacy a generalized treatment standard.  It's too expensive and has too many side effects for a theoretical benefit.  And what kind of message does it send to the patient?    If you're on four medications, how can you be anything but severely ill, all the time?  How can you be responsible for any of your feelings, or for controlling them?

 

9. Diagnose everything

The layman’s argument is that psychiatry pathologizes everything:  “well, anyone would be depressed in those circumstances.  How is that an illness?  And why can you get SSI for it?”

But the truth is in the nuances.  When psychiatrists ask you to keep a mood chart, and you report that on these two days your “depression was worse,” what allows the psychiatrist to know that wasn’t normal sadness?  Can a bipolar ever be sad for a month and not be depressed? 

If a person beats his girlfriends, kills cats, and gets brought by the police because he set fire to a rival’s car, is it possible that his Axis I diagnosis is—nothing?  Ok—how many times have you actually written that down?  How many times have you terminated the “treatment,” or refused to uphold an involuntary commitment order, because the case was not psychiatric?  I know, the system does not have a good mechanism for doing this.  I feel your pain.  But every time we give some vague “Not Otherwise Specified” diagnosis or pass them along to the inpatient services, we are creating a social policy disaster.  We are confirming to the laymen that we think these behaviors are psychiatric, that they are rightfully our purview,  and ensuring that a) we will be held responsible for dealing with them; b) we will be held responsible for the outcome.






Comments

I generally agree with your... (Below threshold)

November 17, 2006 8:50 AM | Posted by CP: | Reply

I generally agree with your commentary here -- especially regarding polypharmacy. Every time I hear of a patient on two antipsychotics, two antidepressants and a benzo, I really worry about what the hell his/her psychiatrist was thinking!
In my view, the most important part of your post was the calling out of psychiatrists to take responsibility for their own education. I think that part of the problem lies in the coursework that is not required. In many programs, there is no requirement for any in-depth training in stats or research methods. You and I both know that articles are often written in a slanted manner to favor the sponsor's product. Without proper education on stats/methods, how can physicians cut through the BS and see what study results actually mean?
I'm willing to bet that most docs assume that a significant p-value means there was a meaningful treatment effect. On a related note, many docs may have no idea of how to calculate or interpret an effect size, so they may just end up taking the authors' word for it when a drug with a minimal treatment effect is declared to be of great clinical utility. These are only two of a large number of potential problems that emerge when docs aren't trained properly. You can also bet that their advertorial CME training won't teach them to examine research scientifically.
As is clear on my site, I think it's fine to blame Big Pharma for many problems, but the problem emerges from the combination of poorly educated (in research) docs, journals whose editorial standards are weak at best, academics who are inextricably linked to the drug industry, and the drug industry itself, which clearly places profitability over patient welfare.
Below is a link to a post where I discuss one particular study that would not have passed muster in an introductory stats class yet made its way into a highly cited psychiatry journal. These types of articles are abundant, as are overly positive review articles by authors who are paid relatively vast consulting fees by drug companies.


Zoloft for PMS

Vote up Vote down Report this comment Score: 1 (7 votes cast)
You don't know what ... (Below threshold)

December 25, 2006 9:34 PM | Posted by Anonymous: | Reply


You don't know what you are talking about regarding addiction: confrontation can do harm and there are better ways of getting people into treatment than staging a big confrontation.

CRAFT family therapy was at least twice as effective at getting family members into treatment compared to the traditional big confrontation advocated by Johnson. The biggest reason was that most families won't go through with the big confrontation, anyway-- and it can create unrealistic expectations of rapid cure that sour family members on recovery when the person relapses.

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A mistake web authors make ... (Below threshold)

December 26, 2006 6:25 PM | Posted by Matt S: | Reply

A mistake web authors make is white text on black. You may well have had a great essay, but since I pretty much could not read it I'll never know.


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"But every time we give ... (Below threshold)

January 1, 2007 4:10 PM | Posted by Passing Through: | Reply

"But every time we give some vague “Not Otherwise Specified” diagnosis or pass them along to the inpatient services, we are creating a social policy disaster. We are confirming to the laymen that we think these behaviors are psychiatric, that they are rightfully our purview, and ensuring that a) we will be held responsible for dealing with them; b) we will be held responsible for the outcome."

Couldn't agree with you more. Psychiatry frequently (and then some) sticks its nose into situations it has no competence in, or right to interfere.

I began adult life as a moderate supporter of psychiatry/psychology. But some decades of experience in the medical system later (including research relating to supposedly psychiatric disorders), I now hold the view that until it gets its methodological and ethical house in order, psychiatry's claims to authority should be seriously downgraded, especially concerning medico-legal judgements (don't get me started on that).

No offence. You seem one of the saner psychs around.

Vote up Vote down Report this comment Score: 8 (10 votes cast)
Good article, I agree. Also... (Below threshold)

January 12, 2007 12:44 AM | Posted by justathought: | Reply

Good article, I agree. Also I agree about the white on black. It's not so easy on the eyes, especially with imperfect vision it tends to go blurry in a way I'm not used to.

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What's the tenth one?... (Below threshold)

January 15, 2007 9:20 AM | Posted by curious: | Reply

What's the tenth one?

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Concerning Polypharmacy, if... (Below threshold)

March 3, 2007 5:36 PM | Posted by Greg M.: | Reply

Concerning Polypharmacy, if it takes more than one med to help, what's wrong with using polypharmacy? Whatever works! btw, I really enjoy reading your blog from the perspective of someone with a mental illness.

Vote up Vote down Report this comment Score: -5 (7 votes cast)
Excellent post, I agree wit... (Below threshold)

April 30, 2007 11:32 PM | Posted by TIm: | Reply

Excellent post, I agree with most of what you wrote.

Pts 1 & 2 are tough. I believe empathy > sympathy, but it is important to do more than 'get the facts'. For people who don't know 3....that is just scary.

6 was dead on, 'nough said. Ok, just one thing.....being informed by research is VITAL. Psychiatry could learn something from the PhD programs out there....if you are informed by research, why aren't you at least TEACHING the basics of research?

Can you e-mail #8 to as many hospitals as possible? There seems to always be this push to select one of the fun cocktail combinations, instead of trying one thing, titrating up, and seeing how the pt does. Leaving them on 4 things the rest of their life isn't exactly ideal (if it can be had with less)

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hi, you don't have to go to... (Below threshold)

June 3, 2007 11:55 PM | Posted by colby jones: | Reply

hi, you don't have to go to school to realize that all of this makes since..It's common since. I want to be a pyschiatrist, but I'm not there yet, if any of you can post comments on here and give me some help as to what you love about you job and your patients that would be great thanks.

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You don't know how lucky yo... (Below threshold)

August 13, 2007 7:03 PM | Posted by Hortense Zvonimira: | Reply

You don't know how lucky you are boy. Hortense Zvonimira.

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Interesting read, but...lik... (Below threshold)

September 12, 2007 9:45 PM | Posted by Eric: | Reply

Interesting read, but...like Curious posted, what's the 10th mistake? I only see nine.

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<a href="http://usalpraxana... (Below threshold)

September 14, 2007 6:45 AM | Posted by Ikysyerg: | Reply

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Problems like these occur i... (Below threshold)

September 14, 2007 12:14 PM | Posted by Erik Watson: | Reply

Problems like these occur in a lot of fields. Usually it's just called 'not keeping up with the technology,' but here it becomes something a bit more serious. I live in Canada, and I know we recently decided that doctors had to take a yearly test to maintain their licenses. While this only helps a bit, it's a big step toward ensuring the right sort of mentality, and I can only hope it extends to the profession of pyschiatry.

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and they also said, that we... (Below threshold)

October 21, 2007 3:57 PM | Posted by Joey Hadassah: | Reply

and they also said, that we couldn't last togethe. Joey Hadassah.

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I have visited your site 52... (Below threshold)

November 18, 2007 11:10 AM | Posted by Visitor318: | Reply

I have visited your site 523-times

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Thank you for stating #2: T... (Below threshold)

December 15, 2007 8:49 PM | Posted by Kevin: | Reply

Thank you for stating #2: Taking Too Much History. As a resident it has always seemed intuitively wrong (i.e. counter-therapeutic) to conduct this boilerplate interview. I try hard not to. My goal on the first interview is to listen to the patient and try to establish trust. But, that is compromised considerably because I have to produce this freaking useless note that includes their entire life story "The patient was born the first of three children to an intact family broken by divorce at age 4..." These notes are painfully long, and the required information (especially the social history) makes the interview more of a data collection session...which patients hate (hell, I hate it!)

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You can add to the "not to ... (Below threshold)

March 8, 2008 12:36 PM | Posted by Anonymous: | Reply

You can add to the "not to do" list:

11) Make the patient fill a 15-page questionnaire, which is a combination of social and medical history. Have a yes/no entry that says "did you ever think of suicide?". Be amazed when the patient checks "no", and tells you that the question is too vague. Ask the patient then "would you never consider suicide?". Be very satisfied when the patient finally admits to a hypothetical scenario (e.g. terminal illness), when he does consider it.

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10. WRITE AN OPINIONATED TO... (Below threshold)

September 1, 2008 4:15 PM | Posted by dave: | Reply

10. WRITE AN OPINIONATED TOP 10 LIST.
If you become the last great psychiatrist on the planet through isolative behavior and narcisstic thought, then do NOT write an opinionated top 10 list. We know you love your job and have a strong desire to help those with depression, mania, anxiety, substance abuse, and psychosis; but exposing other's ineptitude will not help ease your pain. If you find yourself writing a top ten list; stop now, grab a tissue, and consult a colleauge as you my friend may be the patient.

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Yup, what is No.10?? ... (Below threshold)

September 25, 2008 5:09 PM | Posted by confusedinlife: | Reply

Yup, what is No.10??
I found it very funny when author wrote, "If the psychiatrist says more words than the patient, then the psychiatrist is the patient.." as my shrink seldom talks.,,,But I felt like I was talking to air. LOL So now I am always waiting for my shrink to ask me questions...and I kept the answers short ..LOL :)

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I am not convinced you have... (Below threshold)

September 27, 2008 4:32 PM | Posted by Dr. John Mifsud: | Reply

I am not convinced you have any real experience in psychiatric practice, sorry.

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The result of a recent meet... (Below threshold)

November 17, 2008 8:52 PM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

The result of a recent meeting of the minds at my clinic: the quadrupling of our intake questionnaire. I can only imagine how this meeting went: no idea for a new question was a bad idea. Patient hate it, needless to say.

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I'm pretty sure psychiatris... (Below threshold)

January 10, 2009 11:38 PM | Posted by Ashley: | Reply

I'm pretty sure psychiatrists go to school for a good amount of time to know what they're doing. Don't get me wrong, there are some shitty psychiatrists. But, categorizing them all, in a list called "The Ten Biggest Mistakes Psychiatrists Make" is pretty stereotypical. They went to school for 13-15 years. That's a really long time. They studied the brain, in classes at college that you've probably never even heard of. Give them a break, they know what they're doing.

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If you don't make Mistake #... (Below threshold)

February 19, 2009 1:50 PM | Posted by Antidrugrep: | Reply

If you don't make Mistake #2 (thorough history), you're more likely to make Mistake #3 (ignore "co-morbidities"). I hate the term "co-morbidity", it's like the term "side effect", marginalizing the importance/prominence of an effect because it's not the effect you really want to deal with. They're ALL "morbidities". Just because your specialty is psychiatry, that doesn't excuse you from your basic medical training. No, I'm not expecting you to admit and manage my COPD exacerbation with diabetes and a history of 3 heart attacks. But Jeez...you acknowledge the importance of those lifestyle-oriented "co-morbidities", here's a pat on the back. Do you think there might be anything ELSE in a thorough medical history that might affect someone's depression/anxiety/psychosis/whatever? Beta-blocker use? Anti-seizure meds(my bad, that's supposed to HELP)? History of thyroid disorders? And if they DON'T, maybe a solid review of systems could give you a clue? Oh, right: that's the internist's job, the one that does the intake for the psych unit. Grow some perspective and take a little responsibility, Alone. A thorough history could make everyone's job - including YOURS - a little easier.
-A grubby primary care type.

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horse shit... (Below threshold)

February 25, 2009 1:48 AM | Posted by MARK: | Reply

horse shit

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Number ten is provided by t... (Below threshold)

June 2, 2010 9:55 AM | Posted by ThomasD: | Reply

Number ten is provided by the title of the blog. Great post although I also disagree about the "intervention" for the addict. Sometimes this works, but it all depends on what is going on. I find that putting as many contingencies in the way of continued drug use works best: you can use the car as long as the random UDS is negative, etc.

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I have been a psychiatrist ... (Below threshold)

June 13, 2010 12:48 AM | Posted by drdave18: | Reply

I have been a psychiatrist for 20 years, and I really enjoyed this. Appropriately cynical, but not over the top. while I don't agree with everything in this essay, I think a lot of it rings true in a common-sensical way. I don't entirely agree with the stance on history taking. While exquisitely detailed histories and notes are unnecessary, I think there are specific items that should be covered in each note, and I write while I see a patient, but I also spend a lot of time listening and making eye contact. I have a form that I use for the initial history and for progress notes that includes all the basics. My goal is to have 90% of the note written by the time the patient walks out, so I can move quickly to the next patient and so I can everything in writing while it is still fresh in my mind. I spend a lot of time working in corrections, and due to the litigious nature of prison inmates, I have had to defend my notes in court more than once. It is at that time that I am happy I have the information I need at hand, and I can prove that I hit the high points.

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confusedinlife - Why would ... (Below threshold)

June 13, 2010 10:14 AM | Posted, in reply to confusedinlife's comment, by Anonymous: | Reply

confusedinlife - Why would you bother playing those kinds of games with your psychiatrist if you're actually trying to get help? You may be a bit less confused in life if you just started being honest with yourself and others. Withholding information or trying to say less than your therapist only harms you and you're effectively depriving yourself and not the therapist (they're not your parent, they don't love you so they don't feel deprived when you withhold...like I said, the only person you're actually withholding anything from or punishing is yourself since you're the only one who loses out by that kind of behavior). The therapist gets paid no matter how you act out or don't engage with helping yourself. If you have an issue with how much he or she talks or doesn't, why not just be honest with them about how you feel about therapy?

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I have found just the oppos... (Below threshold)

August 21, 2010 4:29 PM | Posted by Anonymous: | Reply

I have found just the opposite to be true of numbers 5 and to a lesser extent 1in my experience many psychiatrist's can be cold or aloof making it nearly impossible for the patient to feel comfortable or trusting during treatment

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Hahaha that was great!!... (Below threshold)

August 21, 2010 9:03 PM | Posted, in reply to dave's comment, by Anonymous: | Reply

Hahaha that was great!!

I've read this guy's blog from time to time, occasionally it's enlightening but most often just entertaining. Always notable is the narcissistic/grandiose style of "the last psychiatrist" who frequently maligns his colleagues and portrays himself as the keeper/provider of wisdom. He ventures into every topic imaginable from psychiatry to pop culture and current events, says he's a psychiatrist and then tells psychiatrists that its not within the purview of their profession to comment on such huge social issues with profound cultural mental health implications as gay marriage.
Is this guy a psychiatrist? I have my doubts. He's certainly not one who has been through or benefited enough from the psychotherapy that he attempts to teach us about. I do hope he has a good therapist of his own, or gets one soon. He is a very intelligent, clever, and funny guy, which is the most difficult type of narcissist precisely because he has plenty of evidence to back up much of the false, superior self that he believes himself to be. This also makes him less likely to seek therapy. Good luck to that therapist.

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"Sometimes people don’t nee... (Below threshold)

November 17, 2010 7:55 AM | Posted by Anonymous: | Reply

"Sometimes people don’t need to know" is absolutely terrible advice. How can you justify not telling a patient what a medicine can do to them? Informing and educating patients is incredibly important in all branches of medicine. And speaking from experience, there are few side effects that will turn people off of drugs that aren't immediately noticeable. If you have thyroid damage, you and your doctor will notice, and adjust medication as necessary.

Look up what "pharmacokinetics" is in regards to polypharmacy. Your explanation makes sense to the lay person apparently, but studying the neurochemistry/biology of drug interactions shows your argument to be... totally based on conjuncture. There are more than one type of dopamine receptors in the brain, and medicines deal with different ones in different ways, or maybe focus on one. Medications to treat the same problem act in different ways. If they didn't, what's the point of creating more than one? SSRI's are never prescribed together because, yeah they do the same thing, but if two are warranted, an SSRI with a high affinity for serotonin receptors is prescribed.

If you're going to attack psychiatry, or pharmacology, you're need more than the "logic" here. Maybe some time studying these things would help? It's really important to realize what you DON'T know. The issues you bring up aren't so simple that you can write from any position of authority with actually devoting a few years to studying this stuff.

Also, lehren Sie bitte Deutsche - Wovon man nicht sprechen kann, darüber müsse man schweigen.

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Oh, I didn't realize people... (Below threshold)

November 17, 2010 7:58 AM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

Oh, I didn't realize people reading this thing you're a psychiatrist. whoops.
I would have to disagree with them, I doubt you have any experience in the medical field.

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At least 25 years shorter l... (Below threshold)

November 17, 2010 10:19 AM | Posted by bbj: | Reply

At least 25 years shorter life is what to expect for people on standard psychiatric medications for mental health issues and-or drug abuse -- according to statistics from SAMHSA and investigative journalist and author Robert Whitaker and hosts of other honest researchers/doctors/psychologists/ and a few honest, enlightened psychiatrists, of which TLP is one.

The drugs are toxic. There is every reason to educate patients, family members, the public and figure out whether the treatments are worse than the suffering they are supposed to alleviate.

Good article and some interesting comments. Thanks!

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"What’s the interaction ... (Below threshold)

December 8, 2010 6:28 PM | Posted by Anonymous: | Reply

"What’s the interaction between Prozac and hydralazine?"

I had to look up hydralazine, but on finding it's a muscle relaxer I can take a wild guess at this one. The first things you'd notice would be sedation: drowsiness, impaired muscle control, lethargy, etc. S/he might also get dizzy on standing up, and might have a slightly abnormal heart rhythm -- increased if there's more Prozac than hydralazine in her system, decreased if it's the other way around. (The latter is from my experience mixing Flexeril and Celexa.) If she does this often or if the doses is are high enough it might harm her liver and CNS; I'd suggest she talk to an MD and/or a pharmacist about this, and that she ask an MD about getting one of the standard "What's going on here?" blood tests.

I'd also want to know if she was just out to relax & have fun or if there's something going on with her besides drug use, and make appropriate referrals; in any event I'd suggest to her that she not make a habit of this and that she not add booze or other psychoactive drugs, including OTC ones like Benadryl, to this if she does it again. And you should tell her that she might avoid driving when she's doing this, even if she doesn't feel fucked up.

This stuff is just common sense. In terms of lasting, more specific effects of mixing Prozac and hydralazine, like whatever the CNS and liver damage might be, I have no idea. That's what MDs and pharmacists are for. But then again I'm not a trained professional, just some guy who looks up the shit I'm doing and tries to remember what I can understand of it.

If you want to challenge somebody's knowledge of drug interactions you might want to think up an example that'd be a little harder, like, oh, Wellbutrin and an antimalarial. I'm guessing it that mixture might make a person cranky, but then I've never taken an antimalarial or had any reason to memorize the contraindications and side effects -- I just recall reading somewhere (a Graham greene maybe?) that the treatment for malaria made somebody cranky, and I know that Wellbutrin can have that effect on me, so I'd expect mixing them would have more of a chance of doing that.

So how'd I do, Doc?

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There are so many bad smell... (Below threshold)

June 23, 2011 5:19 PM | Posted by Chris Johsnon: | Reply

There are so many bad smelling buttcracks in this world that I would add not stressing anal hygiene enough. I could care less if the patient smokes themself to death, but make me sit through a 30 minute appointment with someone who has poor anal hygiene...No way JOSE!!!!!!!!!!!!

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psic doctors dont know anyt... (Below threshold)

July 10, 2011 11:49 PM | Posted by Anonymous: | Reply

psic doctors dont know anything just studied what someone else wrote not science liture made up stuff so you can drug someone legal murders

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I agree with some stuff her... (Below threshold)

July 11, 2011 2:47 PM | Posted by Ellie: | Reply

I agree with some stuff here but not telling your patient the side effects of the medications you've decided to prescribe for them and demanded they take? Are you kidding? I mean yeah, contextualise them. Clozapine can cause WBC toxicity in rare incidences and that's why we constantly monitor you when you're starting treatment or increasing the dose. Some really serious things can go wrong and some minor things. And as soon as something does go wrong and the patient through google search finds out it could be sure to their medication do you think they're going to trust you or another psychiatrist any time soon? It really annoys me as a nurse when the patient has had their medication change and they find out at dinner time in front of all the other patients or when you ask them why they're back in hospital and it's because they've stopped taking their medication because they think they might be gaining weight from it. It may be difficult to talk to a patient about medication, especially if they're paranoid or just a histrionic hypochondriac but deal with it. That is your job. You have a duty of care to tell the patient, not their spouse that this medication is going to change them in more ways then one. And if you can't respect that patient as a person enough to think that they may be able to make a rational choice with a known list of consequences for each action then you can't argue that they should take responsibility for managing their illness; you've taken that away from them. They're not sufferers of bipolar; they're developmentally delayed and need someone to take all the nastiness away. How do they do their ironing without crying at the fact they'll gave to do it again tomorrow? Or do you only tell their husbands and pretend to buy new shirts even though they can plainly see and feel that they are wearing the same shirt again?

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You fucking monster !!! I h... (Below threshold)

August 10, 2011 8:58 PM | Posted by the clients/consumer/patients: | Reply

You fucking monster !!! I hope your life is hell and get mentally ill and treat yourself and polytreat yourself to death !!
yOU IGNORANT coleric basterd.

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superb material for my rese... (Below threshold)

October 6, 2011 1:46 PM | Posted by zenia: | Reply

superb material for my research thank you.....!

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"It is maybe the most profo... (Below threshold)

October 6, 2011 10:36 PM | Posted by Former Patient: | Reply

"It is maybe the most profound disservice of all to tell a patient that their depressive or bipolar symptoms are the result of biology or chemical imbalances and thus absolve them of the responsibility of learning new ways of interpreting and coping with their environment."

Thank you.

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Two years ago I conducted a... (Below threshold)

December 26, 2011 3:45 PM | Posted by Nell: | Reply

Two years ago I conducted an experiment. I went to a psychiatrist and I told him very little about my past, I omitted the fact that my Mother was diagosed with BP, that both she and my Brother attempted suicide and I said nothing about my bad reaction to SSRIs. I said nothing about how my patents divorce was devasting to my family - why should I - I was 46 and worked all of that out in therapy years ago.

Instead I described in detail my symptoms and my lifestyle and stressors.

I did this because I wanted the psychiatrist to diagnos me based on what was in front of him and treat me accordingly. I also did this because I know from experience that most psychiatrists would rely on my family history to diagnos me or assume that because I cannot tolerate SSRIs I am therefore bipolar, which would be supported by my family history.

The result was the first true diagnosis I have ever received and I was guven a treatment plan that was amazingly successful.

Go ahead be outraged, call me a liar. But it worked and I recieved the help I needed.

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This is very attention-grab... (Below threshold)

March 27, 2012 9:53 AM | Posted by Business Card Printing: | Reply

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This guy can't be a psychia... (Below threshold)

July 20, 2012 2:40 AM | Posted by Cristina: | Reply

This guy can't be a psychiatrist. The psychopharmachology part in particular was ridiculous, does he even know how complicated psychopharmachology is, how big are the books..let's throw them away he managed to explain psychopharmachology in three lines. I don't even think this guy went to college.
And, dear writer, about the phamachologic interactions: you can be sure psychiatrist, but also medical students, know them, especially simple ones like the example you mentioned.

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Perhaps the only difference... (Below threshold)

September 23, 2012 1:03 AM | Posted by Or: | Reply

Perhaps the only difference between the NFL and the APA on gay marriage is that NFL players aren't trained to make their opinions sound apolitical:

http://deadspin.com/5941348/they-wont-magically-turn-you-into-a-lustful-cockmonster-chris-kluwe-explains-gay-marriage-to-the-politician-who-is-offended-by-an-nfl-player-supporting-it

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wrong... (Below threshold)

September 24, 2012 1:54 PM | Posted, in reply to Former Patient's comment, by Anonymous: | Reply

wrong

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Havent you read, psychotrop... (Below threshold)

September 24, 2012 11:00 PM | Posted by crazy?: | Reply

Havent you read, psychotropic drugs cause 40,000 deaths a year in the us, and there is NO proof that it corrects any chemical imbalance. Freud Prescribed opium and heroin was the medication for many years, how about blood letting and lobotomies. The whole thing is a scam and cotrolled by the drug companies and chimanzees right the book of diagnostics.

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i go to a psych, i have adh... (Below threshold)

October 6, 2012 12:14 AM | Posted by john: | Reply

i go to a psych, i have adhd ptsd depression alcoholism and polysubst abuse but i am clean now 4.8 yr all he ever talks about is quitting smoking i am tired of it really time to move on i dont care if its the presidents health care initiative i really dont

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The title says "10 biggest ... (Below threshold)

November 15, 2012 2:52 PM | Posted by anon: | Reply

The title says "10 biggest mistakes". I only see 9 listed so am happy to add the 10th - that is the mistake of downplaying the importance of moral responsibility and the family and promoting the individual. This ushered in the "me" generation from which our society has never recovered. Among other problems, we are now confronted with social isolation and its ramifications in our society, as one result, because grown children are doing their own thing or are holding grudges. Is this good mental health? Moral responsibility is lacking. Wm Doherty addresses this in his book, Soul Searching.

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It's merely a detail, but a... (Below threshold)

December 11, 2012 10:45 PM | Posted by Addict: | Reply

It's merely a detail, but an important one. Remember I read it years ago and nodded - "He got it."

2. It is an addiction, so it is psychiatry’s business.
...
All of this applies equally to soda consumption or even diet in general.

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10th mistake: you bored me ... (Below threshold)

January 5, 2013 11:12 PM | Posted by Anonymous: | Reply

10th mistake: you bored me to death.

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I think you got sympathy an... (Below threshold)

February 7, 2013 1:19 AM | Posted by Antoine: | Reply

I think you got sympathy and empathy backwards. Great article, but dude...

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My beef w/ psychiatry is th... (Below threshold)

March 9, 2013 7:03 PM | Posted by Puddytat: | Reply

My beef w/ psychiatry is the awful conditions many (if not most)psych e.r's are in.

* More akin to a dungeon or prison, than human beings needing tx. and understanding.

* Damaging in itsefl wh/ IMHO exacerbates the copndition of the patient already

* Brutal, ignorant contact w/ the security staff, who behave as c.o.'s rather thanadjunctive staff maintaining safety

You shrinks ofetn BEG the public to "Come forward more" for psychiatric TX, and yet do absolutely NOTHING about the conditions I've pointed out??!

[Slowly shaking head at how incredible you guys' priorities are]...

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You need to prove that psyc... (Below threshold)

March 9, 2013 7:26 PM | Posted, in reply to Puddytat's comment, by Anonymous: | Reply

You need to prove that psychiatric ERs are really like that first.

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It was not only my personal... (Below threshold)

March 14, 2013 7:55 PM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

It was not only my personal experience but I have discovered that this has been true for MANY consumers, anonynmous! And your "Aw, tweren't nuthin'!" attitude is what KEEPS US AWAY in DROVES... If you din't have 1sthand experience of what I and PLENTY of others have been through in such units, then you have no right to deny what WE OURSELVES experienced, right?! Further... these days NO one denies that the elderly are often abused in nursing homes, that "different" or smart kids are often bullied in school, yet when we pt.s come forward w/ less-than-glowing reports on degrading and brutal conditions in such units as I have described, we get naysayers like you, who have NO idea what they're defending or simply in denial about.

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3. Ignore smoking cessation... (Below threshold)

March 20, 2013 5:14 PM | Posted by tellMOREabouKIT: | Reply

3. Ignore smoking cessation (any dependency)

Why is this important? Not trying to argue it's not, it is. But why is it relevant for healing/changing mental conditions which per se isn't about addiction?

Or perhaps I got it all wrong. One could say that all mental suffering is due to....(something related to addiction). I don't know.

My take is that change require discipline.

Would love it if some random genius shared his sight of view on this. Why should I quit smoking smack given that I have no life to look forward to?

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yes and the 10th mistake is... (Below threshold)

May 19, 2013 10:38 PM | Posted by Zombie: | Reply

yes and the 10th mistake is trying to follow whatever rubbish has been written by some half-witted person who calls himself "THE LAST PSYCHIATRIST"

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It is maybe the most pro... (Below threshold)

July 18, 2013 8:59 AM | Posted by Anonymous: | Reply

It is maybe the most profound disservice of all to tell a patient that their depressive or bipolar symptoms are the result of biology or chemical imbalances and thus absolve them of the responsibility of learning new ways of interpreting and coping with their environment.

As a former psychiatric patient I've been circling around this idea for years, but never had been able to put it so concisely. Never improved during the time I thought I had a disease - only once I stopped believing in my diagnosis did I do any real work toward recovery.

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I think number ten should b... (Below threshold)

July 18, 2013 10:23 AM | Posted, in reply to curious's comment, by Anonymous: | Reply

I think number ten should be that psychiatrists should not be in the business of covering the easily recognized medical mistakes of other doctors by defaming patients with "lacking in validity" disorders and mandating they take drugs with six concurrent major drug interactions at above FDA recommended levels simulataneously, while hypocritically pretending to be a doctor there to help the patient.

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Call someone a patient! For... (Below threshold)

July 18, 2013 3:19 PM | Posted by AD: | Reply

Call someone a patient! Forget that he/she is a person who may be wrongly referred to you.

Criticize previous psychiatrist's prescription out loud.

Promise a complete recovery "only if" the course of medication is followed regularly without fail.

The moment a person enters your room for consultation, start making assumptions about his background, symptoms, diagnosis, prescription size, etc. (Your teachers might have boasted of how they can tell about the entire diagnosis looking at the 'patient' in the door itself, but that doesn't have to be the way to do it. You can still talk and ask questions)

While in Private practice, ignore specializing for the sake of "business".

And here's is an important one according - Put up your board and wait for people to turn up for help! Who wants to enter a building to get stamped as a psychiatric patient?!

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AD, I agree 1000% w/ you!!!... (Below threshold)

July 18, 2013 5:42 PM | Posted by Puddytat: | Reply

AD, I agree 1000% w/ you!!!

Shrinks talk a lot about "asognosia" which means a patient's (alleged) lack of insight into their illness, but shrinks often seem to forget that THEY TOO are human, and often lack enough insight so as to give a wrong diagnosis to a patient or merely label them "delusional" even if said clain of patient is true. There seems to ehb no set criteria for calling a patient delusional, even if what they desfibe is not physically impossible.

This is called the "Martha Mitchell Effect".

Look up more about this on the web, please, for all who care to investigate this phenomena further.

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All I know is I have been s... (Below threshold)

October 19, 2013 3:17 PM | Posted by Jesse: | Reply

All I know is I have been searching for a psychiatrist who actually cares for six months now and my downward spiral continues because all they care about is the next patient getting the money they don't believe me they don't believe my therapist and I am headed towards disaster. The biggest mistake that psychiatrists make is not caring about the individual.

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Jesse, Keep your spirits up... (Below threshold)

October 19, 2013 3:26 PM | Posted by AD: | Reply

Jesse, Keep your spirits up. If you believe in your therapist and yourself, you will soon come out of this. You will not meet with disaster unless you allow it to happen. Do not allow!

"The biggest mistake that psychiatrists make is not caring about the individual."

Psychiatrists are NOT trained / screened for ability / interest for caring about people. Period!

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Am Sharon Mabe am a busines... (Below threshold)

December 5, 2013 8:19 AM | Posted by Sharon Mabe: | Reply

Am Sharon Mabe am a business woman and i do invest a lot on my business but everything don't go on well my business always going down i always have great loss and other of my friends who we are in the same business are always making it, so i just believed that the devil is at it again but i thank God this man of God called Dr Lumba came into the picture i came in contact with this man after reading some wonderful things about him which then i asked him if he can help me pray for my business and that i just took a loan so i can start again so Dr Lumba told me not to worry that i should just kindly said part of the money to him so he can pray on the money which i did i never got scared of him ripping me off my money because i kindly believed in Dr Lumba so then after i sent him the money he did some prayers on it and after 2 days he sent back my money and then i invested the money into my business believe with 3 days my business started flourishing people where liking my product from different countries and i even paid back the bank there money before it lapped the months i told them i would pay off when i paid back the bank they where shocked saying its just 1 week that i took this loan and now i am paying off i said yes that lots of people paid ahead and demanded for more stuff so i needed to supply them so i just had to pay you people off, am so happy my friends are wondering how i made everything so easy but they don't believe me when i say its the God of Dr Lumba who has helped me out am so happy that at last my business has improved please in case you need any help about your business just kindly contact DR LUMBA ON drlumbahomeofsolution@gmail.com or cell number +2348112867024

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I seriously did poo in my p... (Below threshold)

December 8, 2013 12:12 PM | Posted by Santan Cruz: | Reply

I seriously did poo in my pants due to the nature of hypotenuses & diposmaniacal animalcules.

Makes perfect sense, because, wait for it. . .

If you've just quit your clozapine cold turkey & are ready to make love to the universe. Help me!! I need a psychoanalytic psychiatrist like this guy to make me want to not trust doctors and pantyliners.

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Hello, thank you for this. ... (Below threshold)

December 13, 2013 11:01 PM | Posted by Abby: | Reply

Hello, thank you for this. I've had psychiatrists that were great for me and psychiatrists that were wrong for me. Most were wrong for me. I remember one doctor who would never make eye contact with me and spent more time adding medication then asking me questions and listening to my answers. My most previous one, I felt didn't look at me as a person as much as a patient. I felt worthless when he would point out my flaws to try to make me change but he just didn't see anything positive. I tried my best. And then I had this one woman who kept focusing on how I moved my fingers. What do you think I'm doing? I'm a 10 year old girl in front of a doctor. It's intimidating. I was diagnosed with bipolar in middle school. I'm an 18 year old woman and I'm doing a hell of a lot better. Guess what? I don't take medication anymore. It's true you can change yourself, all you need is a little tweak. I just wish I didn't feel so powerless in the psychiatric office. Thanks again.

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This article's comments on ... (Below threshold)

January 19, 2014 10:28 AM | Posted by CromAnvilofCrom: | Reply

This article's comments on medication being a waste of time for ongoing treatment is something I partly disagree with. Certain disorders are solvable by the patient through their own effort in therapy, or at least they can cope with them better that way. I think therapy helps somewhat for anxiety or depression, depending on the severity. I say somewhat because I myself have suffered on and off throughout my life from anxiety-related stuff and OCD, and I have a friend with terrible clinical depression, and therapy...ehhh, it helps to some degree.

On the other hand, when someone flies off the handle and stays off the handle, screaming their asses off for hours with Bipolar Disorder, or suffers from Schizophrenia..I'm not really sure how the author expects any of these people to pull themselves up by their bootstraps? A lot of these things are basic chemical problems - too much Dopamine, you go bonkers, reduce it somewhat in critical areas of the brain, and you settle down. You can talk all you like in therapy, I don't think it makes any difference to that sort of question. It's like if your legs are blown off at the knees, and the physician states matter-of-factly, "well, the patient's just simply got to learn to walk again." Ummm, with what?

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I agree with you on this. ... (Below threshold)

April 10, 2014 1:35 PM | Posted, in reply to Nell's comment, by Ellen: | Reply

I agree with you on this. I know that when I was a teenager, I went to a therapist/psychiatrist by order of my mother. The reason she had me going was because I fought against committing to every single church activity (obligation) at my friend's church. When I was three years old, my father committed suicide. I am sure that it has done a lot of damage to our family core, mostly my mother who was raving bit*h. But every time we went to a psychiatrist or counselor, my mom would always bring up my father's death as if it were the root of ALL my problems. I disagreed and even said that a lot of my problems were due to my mother, physically and mentally abusing me. Back then, it wasn't something that was reported to the police, so she got away with it. The therapy never worked because they were always focusing on how my dad's death is not a reason to not go to church activities. Ironically, it wasn't. What should have been done was to take notes on what happens every time I go to my friend's church. It would have "cut to the chase". I didn't like that church, nor did I believe in the credo of that church. So, to wind this down, I do agree with you that early history in (your/my) life does not always apply to every situation, especially ones that can be worked out on there own. Which I did. And three years ago, my mother finally admitted that she did a lot of things that she feels bad about. Not to be mean, but she should. I think that things would have worked better without the therapy if my mother would have actually listened to my reasons why for my objections to some things, and to stick up for me instead of people who really didn't matter in the first place (church congregation). When I went to that church, my mom was trying to impress everyone there by taking there side over mine (brown nosing). That is main reason why I wasn't respected or treated well at that church.

I will add that with the therapy I had, the therapists - 2. Took too much history, 3. Ignored smoking cessation; it never occurred to them that removing myself from a situation might resolve a problem, which wasn't an option for my friend's church, 5. Social policy analysts; for this one if it were brought up what I believe about something, the therapist would try to make me say why I believe A vs B, which I think is a dead issue because it is not even relevant in most situations. So, for #5 issues, it sometimes best to say it, then move on. 7. Thinking Strategically; the way I took this may go hand in hand with #3. If it is apparent that something has a negative effect on your environment, instead of taking notes on feelings, etc., why not just remove it as much as you can instead of wasting more time on it. Finally, #9 Diagnose everything. It is ridiculous that a psychiatrist would try to diagnose everything that comes into a person's life. From my experience on this, anytime I tried mentioning that other people are the same in similar circumstances, there response was always, "We are not talking about So and So, we are talking about you. It is common sense that any person will have a general or sometimes specific reaction (anger or sadness) to different events or occurrances.

With my circumstances, they could have been worked out if there was cooperation from concerned parties. A big reason why the therapy didn't take is because I was handling it on my own without any support, except from maybe the therapist. My belief is if what you are getting from therapy is not effective with the people around you, then it ends up being a waste of time. Let's say that a therapist gives you tips on setting boundaries; you take that advice/information and try to apply it in your everyday life, home, work, church, etc., it won't so well unless you have at least one person (not the therapist) who will defend you. I think that when people around you see that you have at least one valid supporter, they won't bully you as much, if at all.

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Are you a business m... (Below threshold)

May 6, 2014 12:34 AM | Posted by mr larry johnson: | Reply


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Are you a business m... (Below threshold)

May 6, 2014 12:36 AM | Posted by mr larry johnson: | Reply


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"Psychiatry is war"?! When ... (Below threshold)

May 18, 2014 10:11 AM | Posted by Zeke: | Reply

"Psychiatry is war"?! When did these people take sides to become addicts, schizophrenics or whatever? And good lack finding those ten highly motivated people for the intervention! Chances are your delightful colleagues will already have diagnosed them with narcissism and delusions of grandeur and drugged them into the kind of dull, apathetic people psychiatrists seem so keen on.

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Hello everyone this really ... (Below threshold)

June 26, 2014 12:26 AM | Posted by Crystal Morgan: | Reply

Hello everyone this really worked and i am proud to testify also. i saw a post on how a lady got her husband back and i decided to try this Dr Ekpiku that helped her because my relationship was crashing. although i never believed in spiritual work i reluctantly tried him because i was desperate but to my greatest surprise this Dr Ekpiku helped me and my relationship is now perfect just as he promised my husband now treats me like a queen even when he had told me before he doesn't love me anymore. well, i can not say much but if you are passing through difficulties in your relationship try him here is his email Ekpikuspelltemple@live.com of a truth he really helps again his email his Ekpikuspelltemple@live.com

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Another motivation why expe... (Below threshold)

July 11, 2014 2:19 AM | Posted by hospitalkhoj: | Reply

Another motivation why experts top cancer hospitals in India is the labors it put to augment patient awareness, so that such fatal diseases can be diagnosed at an early phase, which aids in increasing the success rate of the treatment.

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I am a licensed psychothera... (Below threshold)

July 24, 2014 1:04 PM | Posted by Anonymous: | Reply

I am a licensed psychotherapist and I agree that psychotherapy and medical treatment are necessary to appropriately mood disorders. I have personally witnessed qualified and gifted physicians bring people back from "the brink", i.e., save lives, quickly with medicines. I have also seen psychotherapists who were "quacks" ... pretending they could "cure" physiologically based mood disorders with talk therapy. Medicine and psychotherapy both have value and there are good and bad practitioners. I hope, in the end, this blog brings hope and not despair to anyone reading it if that individual has a mental health problem.

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HOW I GOT MY HUSBAND BACK!!... (Below threshold)

July 24, 2014 1:45 PM | Posted by Crystal Morgan: | Reply

HOW I GOT MY HUSBAND BACK!!! i want to say a very big thanks and appreciation to Prophet Ekpiku for bringing back my husband who left i and the kids for almost two months. i am very much grateful to Prophet Ekpiku. I pray God almighty give you the strength and wisdom to help more people having similar problem like mine. for help you can reach him on his email address:Ekpikuspelltemple@live.com

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Easy way to join the Illumi... (Below threshold)

July 26, 2014 4:03 AM | Posted by illuminati: | Reply

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WELCOME TO THE GREAT ILLUMI... (Below threshold)

July 27, 2014 3:49 PM | Posted by illuminati lord: | Reply

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Join the Illuminati brother... (Below threshold)

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Rumor is that with personal... (Below threshold)

August 2, 2014 6:25 AM | Posted by : | Reply

Rumor is that with personal development, an additional level of interpretation will manifest itself.

That is at least what a guy told me. He's a scholar, so he should know, I guess :)

PS.

I added the part about personal development myself, to what he said.

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This is an excerpt from m... (Below threshold)

August 2, 2014 8:41 PM | Posted by Tru Harlow: | Reply

This is an excerpt from my blog
Www.curementalillness.wordpress.com
I am trying to spread awareness of the truth of dissociation.

The most effective methods of causing dissociation are believed to be those that consist of inflicting moderate amounts of pain over extended periods of time. Emotional trauma is also important.
The horrific experiences victims are exposed to result in their mind utilizing a defense mechanism called DISSOCIATION. Dissociation consists of the victims consciousness detaching from their bodies (or so it seems to them). The result is a euphoric floating feeling. DID caused by Beta programming only serves as the most drastic form of abuse which stimulates dissociation.

We can utilize this knowledge to show how any survivor of any level/type of abuse can be considered as having any measure of DID it is my proposal that many trauma survivors have on some level dissociation of self. Therapists must gain awareness of this fact and utilize techniques which can facilitate a unity between all senses of self. Self awareness can surmount once we confront past events which we are scared of. And the personal, familial and social ramifications of this endeavor may be great. But in order to create unity within one self, we must be self aware. We must gain confidence. We must be free.

I will be tracking my findings of my readings of Carl Jung, unconscious memories, dissociation, dissonance and therapeutic accounts on this blog. Please open your mind to new thoughts on treatment and the reality of DID in the majority of patients.

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HELLO,WELCOME TO TH... (Below threshold)

August 14, 2014 8:54 PM | Posted by mark lee: | Reply

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JOIN ILLUMINATI CHOICE TODA... (Below threshold)

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Today has being the most ha... (Below threshold)

September 17, 2014 9:53 PM | Posted by pedro morgan: | Reply

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re "polypharmacy" and histo... (Below threshold)

September 18, 2014 2:03 PM | Posted by kelsey: | Reply

re "polypharmacy" and history taking: when my doctor found out that there was a history of bipolar disorder in my family, she was especially cautious about monitoring my SSRI use. This was great because as we slowly increased the dosage I ended up having a hypomanic episode and I knew to call her because she warned me about that, knowing the family history of BP. So then we reduced the celexa, added a mood stabilizer, and when that wasn't enough we added wellbutrin because it acts differently and we knew i couldn't handle more SSRIs. And now I'm doing really well! Also, I take klonipin and xanax for anxiety and they help immensely.

So, I'm taking 5 different things, but we arrived at that carefully and it's what worked best. It's not like my doctor just randomly hurled medicine at me. But luckily I have insurance.

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I'm happy for you and I hop... (Below threshold)

September 18, 2014 9:43 PM | Posted, in reply to kelsey's comment, by johnnycoconut: | Reply

I'm happy for you and I hope you keep doing well. :)

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Disassociation occurs bette... (Below threshold)

September 19, 2014 1:23 AM | Posted by Anonymous: | Reply

Disassociation occurs better with ketamine or MXE......truth! All other niggas are lying!

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I had to read this article ... (Below threshold)

October 12, 2014 4:58 AM | Posted by Darb Hut: | Reply

I had to read this article because of my google search but it obviously got me no where as well as what I have tried to find so far. What do you do when your physiatrist sells practice and takes another job "over night" and your left with no explanations, no appointment, no reasoning, no medication refills, no warning, no nothing. I am lost. And I have lost all faith in physiatrist

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I believe that being an exa... (Below threshold)

October 12, 2014 6:14 AM | Posted by Anonymous: | Reply

I believe that being an example in certain rare contexts means not listening to people, at all.

It's hard to explain. Being reactionary isn't desirable either, I know.

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Hello My name is Mr... (Below threshold)

November 10, 2014 5:28 PM | Posted by Bryan P Davies: | Reply

Hello
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Hello to you all!!Ar... (Below threshold)

November 11, 2014 10:46 PM | Posted by micheal: | Reply

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10. Do nothing... (Below threshold)

November 12, 2014 12:59 PM | Posted by : | Reply

10. Do nothing

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WELCOME TO THE GREAT TEMPLE... (Below threshold)

November 18, 2014 5:16 PM | Posted by Anonymous: | Reply

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People make life difficult ... (Below threshold)

November 19, 2014 4:18 AM | Posted by elder lord: | Reply

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*Are you a business man or ... (Below threshold)

November 22, 2014 7:28 AM | Posted by illuminati: | Reply

*Are you a business man or an artist,Politicians and you want to become
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It's been slowly creeping i... (Below threshold)

November 22, 2014 11:00 AM | Posted by Cry: | Reply

It's been slowly creeping into me, a loss of meaning when interacting with people. Guess I could have done more to crack the code, enabling me to communicate better with those who are trapped in darkness.

It's a code, but not exactly. A code has a one-to-one mapping, a precise translation. It's not ambiguous. You don't know precisely what the metaphors represent, do you?

I'm sure your interpretation is shared by the people you communicate with, of course, that is what makes it possible to talk about these things - whatever they are. A shared interpretation provide feeling of confidence, security, predictability. When people respond in a familiar manner, you experience verification. Everyone can't be wrong. Your interpretation is right.

Correct me, but this process of convergence follows not from rational discussion but people emoting: - "I feel we're on the same page"

Don't get me wrong, you're probably right but still, neither of you know exactly what the discussion is about, it is mostly based on mutual recognition. Most of the details are lost. You're looking at a sketch, an outline, and the discussion is reduced to pointing, vague statements meant to effect a direction, expressions of desire, will.

I'm not saying metaphors shouldn't be a powerful tool, or that it is wrong to exploit ambiguity for plausible deniability.

I'm thinking out loud here, don't know much about how people experience it. What I do know, is that a culture based on a disconnect between surface and content, is a weak culture. It's vulnerable, dependent and since it tend to shy away from truth it won't compete/perform very well. It's a dying culture, finished in all but name.

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[ THANKS YOU ILLUMINATI LOR... (Below threshold)

November 29, 2014 11:16 PM | Posted by MR ERICK: | Reply

[ THANKS YOU ILLUMINATI LORD
ROBESON.]
HELLO READERS
,i want to say a big thanks to Lord Richard,
for giving me the privilege, opportunity and helping
me to become a powerful member of a Illuminati
brotherhood.i have been looking for this opportunity all this while but all to know are vain. i have not see the right person that
we make me a powerful member of the Illuminati
brotherhood...until this my
friend that base in U.K, travel back
home for this new
year celebration,and i make him to know my in-tension of becoming a member of the
Illuminati,and he told me that of
recent LORD MASTER in [ U.K],have
sent one of his powerful
and trusted member to initiate
people in Africa who want to join
the Illuminati society and
my friend gave me the web_sit
which i was able to
contact Lord Robeson with,and immediately i got the email ;altimateilluminatitemple0066@gmail.com and the phone number,
+2348112163945
+2348112163945 quickly i called
him and he instructed me on what
to do which i did right
away.believed in me, me that was
poor in 2013,Suprisely
2014 i started counting millions within the range of 2 weeks my life change.
why i paste this on the internet is
because of my good friend
DESMOND,i have not seen him
again,both of us suffer was scam on the internet by internet
Scammers.please DESMOND
anywhere you are, called me with
that my former number is still going so that i can take you to Lord Robeson,or you called him on this phone number +2348112163945
+2348112163945.... fast
LORD Robeson is real an Illuminati
member..we are 31 people he
initiated all of us are
rich now,we are going to U.K,next
week now for Illuminati
batphoment..... all thanks to
Lord Robeson

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WELCOME TO THE GREAT ILLUMI... (Below threshold)

December 2, 2014 4:55 PM | Posted by illuminati forever: | Reply

WELCOME TO THE GREAT ILLUMINATI WHERE YOU CAN FOUND ALL
KINDS OF HAPPINESS BLESSING JOY IN LIFE. Are you tired with the can of
life you are living today do you want your life to be change totally, and
for your to fulfill your dream then you have the opportunity to join now
so that your life story we be change immediately are you poor and you want to
become rich in life ,like other people or you want to be famous in life,
are you a graduate looking for job. you have to join now. or a business man
or woman or star who want to be fame and powerful you don't have to waste
any of your time, are you suffering in life, make up your mind and join the
Illuminati kingdom to become a wealthy man or woman and also to become
famous and powerful email us at org.illuminati@gmail.com or call us
+2348142730353.

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we are looking for n... (Below threshold)

December 6, 2014 8:03 PM | Posted by ILLUMINATI: | Reply


we are looking for new recruit’s to spread the enlightenment of our organization. we do not represent evil nor do we worship devil. we do not advocate violence or harm against anyone.the Illuminati it a group of enlightened individuals whose focus is to spread truth, knowledge and enlightenment. we advocate peace and only exits for the betterment of mankind.we do not promise you riches or however we can advise you on how to obtain these things only if you truly desire them.if you TRULY seek to become member of the Illuminati then please follow the simple steps below for consideration into our organization. brotherhoodsilluminati@gmail.com or call +23481625885333

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