Psychiatric diagnosis is an ethical issue, not only a medical one

In Germany the ICD (International Classification of Diseases) is what we use in clinical context, for insurance purposes etc. Compared with the DSM there are some differences, for example the definition of PTSD is different in both systems. Some conditions don’t appear in the ICD at all, so it is difficult to convey to the health insurance the severity of the patient’s disorder (this is needed in order to have the treatment granted). In these cases the therapist’s creativity is needed…

Just like the DSM, the ICD is also in a constant development, and sometimes after years we find changes that have been in the DSM already long time ago.

Usually the definition of a disorder also includes criteria for the amount of dysfunctionality needed in order for the diagnosis to be given. So that there is a line between just normal changes of mood and a mental disorder. But that line is of course somewhat artificial.

As @Mat already pointed out, making a proper diagnosis is a useful thing. I used to explain the different criteria of a diagnosis to my patients, and as also pointed out by @Vimala and @Cara this is generally most helpful! In certain cases, especially for serious disorders like DID (Dissociative Identity Disorder, formerly called multiple personality disorder), I would also use the diagnosis manuals in order to make the diagnosis, assessing all the listed criteria very carefully (and this usually is not to be done in a short time).

@jimisommer: Thank you for the courage to share your story here. This is really sad to hear, but unfortunately quite common! One of my patients who at the time fulfilled all criteria of a borderline personality disorder was a medical student and one day heard a lecture about BPD - she came to me shocked! The lecturer had said that this disorder cannot be treated, that these people are just impossible to make arrangements with - in other words: they are bad people and better to be avoided!

Unfortunately this attitude is not an exception in the German professional “psycho-scene”. The knowledge about this kind of disorders among practising psychiatrists and in psychiatric hospitals is sometimes very shallow which not only leads to devaluing people but also to wrong diagnosis as your case has shown. And of course a treatment on the basis of a wrong diagnosis won’t help! I’ve seen so many people from the trauma and BPD spectrum who suffered serious harm from treatment in psychiatric hospitals or with practising psychiatrists!

As @AnagarikaMichael beautifully explained, people with a BPD should find a therapist trained in Dialectical Behavioral Therapy (which - by the way - explicitly uses mindfulness as a skill to be developed). And as the overlap of symptoms between BPD and the various posttraumatic disorders is about 75 - 80 % it would be good if the therapist also has a training in trauma treatment. I’ve met many people with this kind of problems, and they were usually lovely people. Working with them I found mostly very rewarding as many of them feel so grateful to finally find the help they need after many bad experiences! BPD is treatable!

As for the autistic spectrum, as @Mat also mentions, it didn’t occur in my professional training at all (just as if autism is only something children can have, and when working with adults we don’t need to consider this… ). I only learned about it after encountering some people concerned. I could probably have done better justice to some of my patients if I had known earlier.

This isn’t quite true for disorders of the trauma or dissociative spectrum or for some personality disorders. Too often have I seen traumatised people misdiagnosed with pschychotic disorders and given antipsychotic medication which only made it worse! Also, traumatised people should not be treated with classical psychoanalytical techniques but rather trauma-specific techniques, such as for example PITT (Psychodynamic Imaginative Trauma Therapy) developed by Luise Reddemann or EMDR (Eye Movement Desensitization and Reprocessing) developed by Francine Shapiro - the latter being mainly a technique for confronting the trauma which has to be embedded in a broader therapeutic concept.

May all afflicted people find the right doctor for their condition! :woman_health_worker:
Or rather: :buddha:

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Trauma has different meanings in psychotherapy and psychiatry (or CBT)- the latter require re-experiencing (ie flashbacks, intrusive images etc) phenomena for a diagnosis. NICE guidance, AFAIK recommends EMDR and trauma focused CBT for a specific diagnosis of Post Traumatic Stress disorder. It also recommends Mentalization Based Therapy for personality problems. Often people comment on psychiatric medication without much knowledge ie without being a psychiatrist, who knows about their usage. Antipsychotics are used as last line, when other medications haven’t worked, in many non-psychosis diagnoses. Psychiatrists are human beings too and are dealing with more human anguish than most people can stand -especially in inpatient wards- and 95% of our patients do see improvement and lessening of their suffering. Just like a clinician (one article above suggests that diagnosis isn’t something ‘clinicians’ do, :rofl:) who hasn’t seen autistic spectrum disorder many mental health professionals haven’t seen the sever end of Paranoid schizophrenia or Bipolar disorder. They require medication that have been proven to work, when it is not possible to offer talking therapies because they are too disturbed to communicate.

However if rebirth is true, then we have all undergone such suffering- it is time to leave, helping ourselves and others to do so in the process. :anjal:

with metta

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Hi Mat,

I certainly didn’t want to say psychiatrists are not human or are incapable people. If it sounded that way, or if what I said was hurting your feelings in some other way, I apologise, that wasn’t my intention. And I know also quite a few very engaged and competent psychiatrists! Here I just wanted to describe experiences of people I used to be responsible for and who had suffered much harm, and I wanted to confirm that @jimisommer’s case is not that uncommon, at least in Germany (although he is living elsewhere, not sure where).

When I speak of “trauma” what I mean is the one with flashbacks, intrusive images etc. But there is also something called “complex PTSD” which has - as the word says - a more complex symptomatology and doesn’t go back to one single traumatic event but to multiple ones. That was also part of what I mostly had to deal with.

I know that antipsychotics in some cases - also of non-psychotic diagnoses - are necessary and very helpful, and of course in these cases I would strongly recommend them. I’m really not denying the most beneficial effects of these substances! But that’s not the cases I was talking about here. Also, the habits in usage of psychotropic medication in general is somewhat different in different countries. I could see that while working in a psychosomatic clinic in the border region between Germany, France and Luxembourg. In that clinic we established a French language department in order to offer stationary psychosomatic treatment to patients from France and Luxembourg which otherwise doesn’t exist in these countries. And the patients we got from France as well as from Luxembourg often arrived under - for our standards - an unimaginable amount of medication!

I’ve seen some of it, but probably not as much as you.

Probably I should say something about the professional “psycho” system in Germany which is somewhat complex and not so obvious to understand. On the one hand there are psychiatrists who are doctors, i. e. they do medical studies at university, and then specialise in psychiatry. Then there are other doctors - like me - who after their university studies specialise in something that is called “psychosomatic medicine and psychotherapy”. And a third category is the one of psychologists who after their university studies acquire a license as psychological psychotherapists. All three of those can work as psychotherapists; most psychiatrists don’t, so this is mainly the area of the “psychological” and “doctor” psychotherapists. As a doctor I would theoretically of course also be qualified to prescribe medication, but to add to the complexity this wasn’t permitted when I started practising because of reasons of, let’s say, professional politics, i. e. limitations in the number of persons practising in certain areas. So when working in my own practise I was only allowed to do psychotherapy, nothing else. And of course I had to cooperate with my psychiatric colleagues for the medication side, as well as I also would cooperate with sociotherapists, occupational therapists etc.

From your previous post:

Among psychotherapists in Germany it is quite common to have regular supervision and exchange among colleagues. As far as I know this is much less so among psychiatrists - and of course for other countries I have no idea. But this is a very helpful thing to have, especially for traumatherapists as I used to be. One of the pioneers of traumatherapy in Germany, Luise Reddemann, is quoted: “The question is not whether a traumatherapist will develop a secondary traumatisation, but rather when.” Mental hygiene is something very important for health workers in general, and the more serious the problems they have to deal with the more important it is. For me the most important means of mental hygiene has been metta meditation!

In Germany we don’t have the possibility for early retirement for this group of people.

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You misunderstood the article.