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Psychodynamic causes behind bipolar disorder, schizophrenia

Vol. 5, No. 6 / June 2006

The dramatic mental status changes shown by Dr. Lake’s and Dr. Hurwitz’ sample patient (Current Psychiatry, March 2006) speak to the blurred boundaries between major illness categories in DSM-IV-TR. Discovering demonstrable brain pathology or a causative systemic medical disorder clarifies these boundaries.

Dr. Randy Hillard notes that psychiatry is evolving as a specialty (Current Psychiatry, March 2006), but use of atypical antipsychotics to control mood and thought symptoms accounts for much of this evolution. Bipolar disorder and schizophrenia are not biologically different mental illnesses, but rather varying abnormal manifestations of a severe mental process.

Drs. Lake and Hurwitz write that correct initial diagnosis is essential for effective psychiatric treatment. When possible, we must also consider psychodynamic causes of hallucinations, delusional behavior, or mood swings—such as unresolved conflicts and stressors—as well as the patient’s acquired insight before we can make a diagnosis.

Although psychotropics can control thought and mood symptoms, psychotherapy that delves into the psychosocial nuances at the root of the disturbance is crucial to restoring a patient with a major mental illness to sustained life activity. Unfortunately, such psychotherapy is time-consuming, and managed care restricts reimbursement for psychotherapy. In this sense, psychiatry is regressing rather than evolving.

We need to classify functional mental illnesses into major and minor entities instead of a myriad of disorders—as DSM-IV-TR has done—and focus on psychodynamic causes of psychopathology instead of speculative biological differences between mental illness presentations. This will restore sense and meaning to psychiatry as a medical discipline.

Theodore Pearlman, MD
Houston, TX

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