"The experience I’ve had is that really great therapists are born—they’re not taught—and they don’t become great by following a manual," says , now on the cover of our flagship publication, The Carlat Psychiatry Report thecarlatreport.com/articles/4214- #mentalhealth
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Allen Frances
@AllenFrancesMD
Author 'TWILIGHT OF AMERICAN SANITY, A PSYCHIATRIST ANALYZES THE AGE OF TRUMP'
'SAVING NORMAL'
Chair, DSM-IV Task Force.
Former Chair, Duke Dept of Psychiatry
en.m.wikipedia.org/wiki/Allen_Fra…Joined February 2013
Allen Frances’s Tweets
DSM mental disorders are constructs, not diseases. Descriptive, not explanatory.
Helpful in communication/treatment planning.
But no claims re causality/homogeneity/clear boundaries.
Clinically useful when used skeptically.
We wrote all this in DSM-IV Intro- but no one read it.
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It seems to me there's a conceptual puzzle with psychiatric diagnosis, and I’m earnestly seeking illumination, not a fight. On the one hand, I take it that in a normal clinical context, a diagnosis is meant to be explanatory. 1/6
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Given all that can go wrong in connecting our brains' 125 trillion synapses, it's an absolute miracle of evolutionary engineering that we work at all.
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Normal neuron trying to connect with a mutated neuron:
#neuroscience
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My 50 years experience condensed into 12 most crucial tips to avoid misdiagnosis & overdiagnosis
From 'Essentials of Psychiatric Diagnosis'
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Anyone who cares at all about the mentally ill must read this eloquent & deeply moving description of everything that's horribly wrong with our mental health nonsystem:
"I’m an N.Y.C. Paramedic. I’ve Never Witnessed a Mental Health Crisis Like This One."
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Competent clinicians who work with wide range of psych problems almost always follow a common-sense biopsychosocial model.
Extremist biological or psychological or social reductionists are usually academic ideologues with limited hands-on experience dealing w clinical complexity
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Any jerk can prescribe meds but
It takes real medical & people skillsl to deprescribe them.
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Reflecting on @MikeSteinman @UTSWInternalMed #gr:
—Medications are sticky
— Deprescribing is a behavior, and requires motivation (on our and patient’s side) to make change.
—Deprescribing is not just the opposite of prescribing.
@JihaRheum @NamrataRheum @KWyshamMD @UTSWRheum
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Tips drawn from my "Essentials of Psychiatric Diagnosis")
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Good Question:
Why are people who should know better so often completely wrong re #ECT?
My answers:
1)Limited clinical experience
2)Career ambitions
3)Seeking publicity
4)Protecting guild interests
5)Reductiinistic thinking
6)Lack of common sense
Note: None are easy to change.
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Join the on ‘#SelfBindingDirectives: This house believes that people should be able to commit themselves to future involuntary treatment.’ Date: 23 Feb 2023. Register: bit.ly/3f6U7l4
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I was wrong to think Musk would need months, maybe yrs, to turn Twitter into a cesspool of dangerous lies & hate- he's done it in days.
I call on both Am Psych Associations to lead a mass #TwitterMigration of mental health workers & patients to #Mastodon.
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Anyone interested in psychiatric diagnosis should definitely study this great graphic re differing views on fundamental nature of "mental disorder"- & figure out where you stand.
(Spoiler: I see most mental disorders as pragmatically useful constructs- not diseases/not myths)
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13 topics under-emphasized in psychiatric training:
1)clozapine
2)lithium
3)ECT
4)deprescribing
5)psychotherapy
6)work with families
7)medical causes of symptoms
8)substance disorders
9)prison psychiatry
10)community psychiatry
11)work with homeless
12)saving normal
13)advocacy
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I've never known a patient who didn't need comforting at some point during #psychotherapy- & for some patients comforting is one essential part of treatment:
1)#grief after lost loved one
2)difficult life circumstances
3)medical illness
4)severe psych illness
No 1 size fits all.
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Psychotherapy is not about coddling & comforting.
If a therapist has never learned how to do psychotherapy—through meaningful personal psychotherapy + quality clinical supervision—that's what they do instead.
Their patients like them but do not change & do not get well. twitter.com/AAJDeVille1/st…
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"Demoralization" is most missed diagnosis in psychiatry because not in DSM.
Common reaction to chronic stress/psych disorder/med illness.
Symptoms: Dispirited/giving up hope/lost confidence/inactivity
Helped by psychotherapy/exercise/adding good minutes each day/finding meaning
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The two most recent podcasts of TALKING THERAPY by Goldfried & Frances deal with the role that EXPLANATION (insight) vs EXPERIENCING (action) play in the change progress.
YouTube link: youtube.com/channel/UCK-kL…
Spotify link:
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New interview of on the enduring value of psychotherapy in the Carlat Psychiatry Report : "I felt like a better person when I was doing psychotherapy than I did in any other role in my life."
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Bible should be the very 1st book censored from our public libraries & schools.
Kids should not be exposed to its graphic descriptions of:
1)Rape
2)incest
3)Fratricide
4)Genocide
5)Slavery
6)Homosexuality
7)Cheating
8)Lying
9)Honor killing
10)Pornograpy
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Open access review on #ECT shows effectiveness of ECT for those without decision-making capacity at start of treatment
Approx. 80% responded to ECT & many regain capacity through treatment
brainstimjrnl.com/article/S1935-
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Our latest podcast deals with what some folks call "#imposter syndrome." Our title is:
"Competent but not Confident."
YouTube link: youtube.com/channel/UCK-kL…
Spotify link:
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Does a friend, family member, or someone else you care about have suicidal thoughts?
It's hard for the person you care about, of course, and the danger, uncertainty, & fears are hard for you, too.
I wrote a book on how to help and, not incidentally, how to cope.
read image description
ALT
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Most over-diagnosed mental disorders:
1)#ADHD
2)Autism
3)#Major #depression
4)#bipolardisorder
5)#anxiety disorders
6)#PTSD
Most Missed
1)Substance Disorder
2)Medication Side Effect
3)Underlying medical illness
4)Delirium
5)Eating & Sleep Disorders
5)#personality disorder
6)PTSD
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I oppose pathologizing "prolonged grief" by calling it mental disorder:
1)No right length for normal #grief after losing loved ones
2)Grief varies greatly by person/culture/situation
3)Cheapens the dignity of grief
4)Leads to excess meds
5)"Major Depression" better fit if needed
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.
At last, DSM has recognized prolonged grief disorder. I remember discussing this clinically observed problem with a colleague in the late 1970s (when Star Wars first came out!), & we lamented why it had been ignored
This is no way to run a profession!
. twitter.com/APA_Publishing…
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Replying to
Family therapy is often most effective/efficient way to treat psych problems.
Popular til 1980s, but now way underused because
1)DSM focus is on individuals
2)Excess use of meds
3)Not covered by insurance
4)No longer covered in training
I think most evals should include family.
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I've known many 100s of patients whose neurological or medical illness was missed & 1st diagnosed as psychiatric.
And many hundreds whose psych problems were caused by medication side effect.
Make sure to always rule out both of these before making any psychiatric diagnosis.
Quote Tweet
#CME Case Report + Lit Review: New-onset delusions heralding an underlying #neurodegenerative condition in a mid-aged woman where genetics may play a role. bit.ly/3uE7I8F
#NeuroPsych #MedEd #psychosis
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Another nail in coffin of US democracy.
I wont post new tweets in Muskworld, but account will stay open so you can access old tweets.
Was fun (& hope useful) while it lasted- hope Twitter dosn't turn out to be as bad as I fear.
Goodbye & Thank you, al
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I was against including Antisocial Personality Disorder in DSM-III/wanted it excluded in DSM-IV.
Why? Describes almost all criminals/no treatment/confuses bad with mad/forensic abuse.
Lost both times based on historical precedent/grandfathering.
An excellent review of issues:
Quote Tweet
How Do You Diagnose A Personality Disorder? | Psychology Today psychologytoday.com/blog/personali Diagnosed with a personality disorder? Find out the process. 
@AllenFrancesMD @page88 @gtconway3d @PreetBharara @SameiHuda
@AllenFrancesMD @page88 @gtconway3d @PreetBharara @SameiHudaShow this thread
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Most important lesson of my 40 yrs work on psych diagnosis- anything in DSM that can be misused will be misused.
Proposed disorders helpful to describe severe presentations in special settings are harmful when misapplied to normal/mild symptoms in primary care.
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Replying to @AllenFrancesMD
I've seen DMDD in action and it's nothing like temper tantrums. It's an explosive mental short-circuit that requires some sort of therapeutic intervention for the good of the child and besieged family.
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Anyone interested in psychiatric diagnosis should definitely study this great graphic re differing views on fundamental nature of "mental disorder"- & figure out where you stand.
(Spoiler: I see most mental disorders as pragmatically useful constructs- not diseases/not myths)
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DSM mental disorders are constructs, not diseases. Descriptive, not explanatory.
Helpful in communication/treatment planning.
But no claims re causality/homogeneity/clear boundaries.
Clinically useful when used skeptically.
We wrote all this in DSM-IV Intro- but no one read it.
Quote Tweet
It seems to me there's a conceptual puzzle with psychiatric diagnosis, and I’m earnestly seeking illumination, not a fight. On the one hand, I take it that in a normal clinical context, a diagnosis is meant to be explanatory. 1/6
Show this thread
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"Lived experiences" (both patient's & clinician's) have great value, but also a great inherent limitation.
By definition, "lived experience" is unique to each person & doesn't generalize very well to other people's lived experiences.
That's why we also need systematic research.
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GPs prescribe 80% of psych meds- usually after brief visisits with patients they barely know who need watchful waiting- not meds.
90% benzos
80% antidepressants
60% stimulants
50% antipsychotics
So easy to start meds/so hard to stop them.
Quote Tweet
Pharma created symptom checklists that could apply to many people at any given time. Pushed them on primary care to "screen" mental health "disorders". Fits nicely into the 15 minute eval. PCP's have no expertise in this area & use the check lists to diagnose & prescribe. 
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Screening all kids 8-18 for anxiety is dumb/dangerous idea:
1)Causes massive false positive overdiagnosis/stigma/misuse of meds
2)Not enough clinicians to treat kids identified
2)Drains resources better used to improve kid's lives/education
3)Neglects dire needs of severely ill
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An influential group of U.S. experts has recommended screening all children ages 8 and older for anxiety, saying the latest research supports early intervention for younger kids.
More than 7% of children ages 3 to 17 have diagnosed anxiety, the CDC says. nyti.ms/3EcNA0C
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Suggesting routine "Anxiety Screening for All Adults Under 65" is dangerously dumb:
1)Astronomical false + rates
2)Triggers even more massive med overuse
3)Impractical in 15 minute 1° care visits
4)Therapists are already in very short supply
5)Neglects great needs of severely ill
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Health Panel Recommends Anxiety Screening for All Adults Under 65 - The New York Times nytimes.com/2022/09/20/hea
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This great quote from Carl Rogers is also the foundation of Marsha Linehan's 'DBT':
The radical acceptance of who you are & how things are is a necessary precondition to wanting to change & being able to.
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“The curious paradox is that when I accept myself as I am, then I can change.”
- Carl Rogers
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“Pathologising grief is an insult to the dignity of loving relationships; Grief warrants strong social support and compassionate connection, not medicalisation.” I totally agree with and
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Loneliness is the enemy of happy old age & seducer of #suicide.
Frequently "treated" w benzo/SSRI/antipsychotic pills that only make things worse & shorten lifespan.
As population ages, we must help seniors help each other/remain useful/have a role.
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Most frequent cause of new cognitive symptoms in the elderly is overmedication.
Quote Tweet
On average, seniors with #dementia may take up to 8 medications a day — possibly unnecessarily, a new study finds. In those with cognitive impairment, “we worry about drug-drug interactions causing problems,” Dr. @Matthew_Growdon tells @KCBSRadio. ucsfh.org/3M0NgVk
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