Chaya B. Gopin

"Psychiatry has some of the richest yet most poorly understood diagnostic labels in medicine."

This point, in my mind, is what makes labeling particularly dangerous; very often, we are not even completely sure what we are labeling patients with! I do think that it is extremely important to give a title to a disease, as that is what enables doctors to converse with one another about a particular case and provide the most suitable treatment. But, as Raj argues, in the area of mental health, labels come along with a great deal of stigma. Why would a patient, with a currently untreatable condition, want to walk around with a label attached to them?

I think that the other problem with labeling is that people are often over-labeled. With the current DSM system, patients are often overloaded with labels that each account for a part of their presenting symptoms. I actually just saw an 8 year old patient who was previously diagnosed by her psychiatrist with psychotic disorder, NOS, in remission, ADHD, combined type, and a learning disorder, and mood disorder was recorded as a rule-out. When I saw this child's records I was extremely frustrated by the ease with which these highly charged labels were assigned. While it definitely gave me a sense of the type of patient who was about to walk into the office, I would hope that a psychiatrist would be more hesitant to label such a young child with all of those diagnoses. Instead of diagnosing a patient with the most troublesome of the diagnoses, attempting to treat that problem, and then seeing if the remaining symptoms lift, people want to make sure that they aren't the ones to leave off one of the possible labels. As a result, the patient is given some labels that are probably not actually present, and he/she is the one who has to live with the list of labels and their stigmas.

I agree with everyone's comments that the lack of an interpreter is completely ridiculous. In this case, it isn't just a problem of consent, though. The lack of understanding also majorly impacted patient care, and seemingly, the whole reason to push for consent is to be able to provide the patient with the proper care.

I understand that pulling a child out of class to receive services can make the child feel as though he/she is "not ok", but I would think that the same message comes across when that child receives special services within the classroom setting. I don't think that the answer should be that we refrain from giving children services that will improve their functioning b/c it negatively impacts their self esteem. Rather, we should provide them with services and encourage them to participate in activities in which they will experience success, acceptance, and enjoyment. Also, while it is remarkable that Kathie Snow is able to mimic the services that her child was receiving, not every parent has the time or the abilities necessary to do so. While it may indeed be best to do what she is doing, I don't think that it should be recommended for every child/parent.

I find it sad that the Cassell article was published 25 years ago. Have we made any advances at all in this area over that period?

"... a multidisciplinary approach should be taken to patient care, including psychosocial preparation in the preoperative phase and postoperative follow-up. This is necessary to help the patients and their entourage better anticipate and cope with unquestionable success of STN stimulation."

I think that the authors' final point is extremely important and should be a necessary component in all treatment protocols. As much as patients and their caregivers want to find a cure, change is inextricably linked to the healing process, and everyone has a hard time adapting to any form of change. And, while the changes associated with a cure are supposed to be for the better, they may actually be harder to deal with. People often rise to the occasion when they/loved ones are diagnosed with an illness, but I can imagine that it is even harder to "drop" when that illness is no longer. It is hard to resume old roles once new ones have been established, especially because the relationship between the patient-caregiver can't go back to the exact way that it was prior to the illness.

Also, I found it particularly interesting that there seemed to be 2 very different types of dyads: those in which the patient now had a new zest for life and the caregiver experienced some loss of identity and those in which the patient became/still felt impaired and the caregiver no longer wanted to assume that role. While people respond to these situations in a multitude of ways, it seems as though the response is almost predictable based on the patient-caregiver relationship prior to surgery (or in other cases receiving equivalent treatment). I think that it would be particulalry helpful/interesting for these people to interact in a group therapy session in which they could learn from others who are dealing with a similar situation.

I'm wondering what other types of things would also remain in one's memory. Is there something intrinsic to music that makes it completely different from everything else? Or is it that in his particular case and with his training, music became encoded differently? If it is that he retained some memories of things that he really loved, maybe this is the way to help patients retain some sense of self as they their AD diagnoses are becoming more severe- tap into what it is that still speaks to them.

Anyone see "50 First Dates"? I can't claim that I have, but from what I heard about the movie, it's a story about a similar experience (I think post TBI) and very similar approaches to managing the disorientation that results on a moment to moment basis.

I found this reading to be particularly interesting, as I typically think of children/spouses as the caregivers who are struggling to adjust to their family member's diagnosis of AD rather than medical staff members attempting to deal with their patients. Oftentimes, a parent/spouse is sent to a home assuming that the staff members are more capable of managing the patient, resulting in a better enviornment in which the patient can reside. It seems as though more people would think twice before sending the patient to a home if they were to realize these issues in the patient-staff relationship, especially because it comes at the cost of aspects the patient's independence and happiness. If this then results in increased anxiety and frustration, the demands on the staff becomes even greater than they would have been on the family member, which then increases the likelihood that the patient will be infantilized further. Seems like quite the downward spiral to me.

"The chance for heroic rescue is there at least..."

Why is the goal to rescue? Shouldn't it be to treat? And, if the presenting illness is not treatable, than the task should becoming providing comfort and recommendations that will improve the quality of the patient's life with the illness. The search for an alternate diagnosis that would be curable can be detrimental to the patient. I have witnessed this first hand: I had a patient who was referred for a neuropsych assessment as part of a work-up to determine if Deep Brain Stimulation would be an appropriate treatment. The patient's history revealed that he had previously had 21 different brain surgeries, 15 of them in the past 7 years! Seemed a little excessive. Sure enough, his MMPI-2 profile had questionable validity b/c he tended to over report the presence and severity of symptoms, and even so, the general pattern produced revealed a tendency to respond to psychological distress with physical symptoms. This patient would surely benefit from CBT before cutting his head opened, again. But each time, the doctors that he went to decided that their surgery would be the one to rid him of his presenting complaint. While I recognize that it may have seemed, at each time point, that the surgery would be successful, the overall patient (and his medical history) seems to have gotten lost somewhere along the way. A little less heroism would probably have been a good thing in this case.

Thought that people might be interested...
http://www.wnyc.org/shows/radiolab/episodes/2006/05/05