Part One – Is Nick Sick? (11 minutes) |
Part Two – Is Nick Sick? (9 minutes) |
Response to the ‘Is Nick Sick?’ video blog
by Professor Jon Jureidini
“Patrick McGorry’s Orygen Youth Health, CAARMS training video[1] on how to diagnose ‘Attenuated Psychosis’ demonstrates how not to carry out a psychiatric interview and interact with young people.”
As identified by Martin Whitely in his commentary about the CAARMS training DVD, describing Nick as being at ultra-high risk of psychosis (UHR) fails the common-sense test. Even more concerning is that Nick is labelled as having Attenuated Psychosis – in ordinary language, he is already mildly mad.
Professor McGorry justifies diagnosing young people like Nick as being at ‘ultra high risk’ because within the next 12 months they are ‘between two and four hundred times’ more likely to become psychotic than the ‘the general population’.[2]
But we must respect the ordinary everyday language meaning of ultra high risk. If I am labelled as being at ultra-high risk of something, I assume that I will probably be affected. I do not interpret that label as meaning I am simply much more at risk than my peers.
Even Professor McGorry acknowledges that nearly two-thirds of the people identified as being at ultra high risk of developing psychosis, don’t become psychotic.[3] Independent evidence shows the conversion rate is as low as 8%[4] With between 64% and 92% false positives, the true ‘ultra high’ risk is the risk of being incorrectly labelled.
The pay-off for testing for UHR is simply not sufficient to justify the cost. One cost is that Nick is now being taught to see himself as sick. Who knows if this might not even increase this vulnerable young man’s risk of ultimately being diagnosed with full-blown psychosis? And as Martin Whitely points out, it stigmatises him.
But more important to me than stigmatisation is the fact that the UHR label is an unexplanation; it ignores what is going on in Nick’s life. Unexplaining is different from saying ‘I don’t know’ (something we doctors would do well to say more often). Unexplanations distract from the difficult but rewarding task of working with a young person towards finding an explanation for their stress.
Nick makes it pretty easy for the listener. He tells us about being bullied into a trade that he doesn’t want to be in, and he invites the interviewer to explore his relationship with his father. The interviewer doesn’t notice, or chooses to ignore this invitation, instead sticking to a stereotyped list of questions that generate the sterile unexplanation of UHR.
It might be argued that the interviewer would come back to this later. However, in my experience, young people prefer us to show an interest in their difficult and intimate predicaments when they first get the courage to put them into words.
I am grateful to Martin Whitely for putting the CAARMS training video into the public domain because it provides a potential teaching tool for medical students in how not to carry out a psychiatric interview and interact with young people.
For more on this subject see Whitely tells Parliament – It’s time to confront Patrick McGorry’s disease mongering and end the guru-isation of Australian mental health policy
Related Media
Byron Kaye, Medical Observer, McGorry stands firm on ‘flimsy’ accusations 11th Sep 2012 http://www.medicalobserver.com.au/news/mcgorry-stands-firm–on-flimsy-accusations
The following is a transcript of the interview with Nick and the introduction to the CAARMS Training DVD
Associate Professor Alison Yung.:
Hello and welcome to the CAARMS Training DVD. The CAARMS has two functions; First, to assess whether the person meets the ultra-high risk criteria for psychosis or not and second, to assess the range of psycho-pathology which we see typically in people in the prodrome preceding a first episode of psychosis. For this training video we’ll just focus on the first function, that of assessing the ultra high- risk criteria.
For this function we need only the first four sub-scales of the CAARMS; Unusual thought content, non bizarre ideas, perceptual abnormalities and conceptual disorganization. These four sub-scales assess sub-threshold and threshold versions of positive psychotic symptoms, delusions, hallucinations and formal thought disorder.
You notice that the interviewer assesses both the intensity, frequency and duration of these phenomena.
We’re going to show you four interviews of typical people who present to the Pace clinic.
Also in the DVD there will be slides showing the ratings for each of these people.
By viewing the DVD you’ll see both how the interviewer asks the questions and the responses that we commonly encounter at the clinic.
DVD also contains additional information. We hope that this resource assists you in your work.
INTERVIEW 1.
Narrator: Nick is an 18 year old apprentice electrician in his first year of training. He is self-referred to PACE, encouraged by his sister, after confiding in her that he has been extremely anxious and has had great difficulty sleeping. He has not previously sought help for psychological issues but there is a family history of depression in the maternal aunt and of an unknown psychiatric condition in his mother’s grandmother. Nick is single and lives with his parents and three younger sisters. The family is of Italian origin. Nick did reasonably well at school and completed Year 12. He has a large circle of friends, enjoys playing sports and has had girlfriends in the past but is not in a relationship at the moment. He does not mind if his mother knows about his current problems but does not want his father informed.
Interviewer: Okay Nick, so you’ve told me that um things haven’t been going very for a little while now since you started work, I just want to ask you some more detailed questions about the sorts of things you’ve been experiencing. So can you tell me, have you had the feeling that something odd is going on that you can’t explain?
Nick: No, not really, no. (shakes head)
Interviewer: No, Have you been feeling puzzled by anything?
Nick: No.
Interviewer: Do you feel that you have changed in any way, who you are has changed?
Nick: No.
Interviewer: Or that people around you have changed in in some way?
Nick: No, not not really.
Interviewer: Okay, have you felt that things around you have ahh a special meaning or that people have arranged things especially for you?
Nick: No.
Interviewer: No?
Nick: No.
Interviewer: People been trying to give you any messages?
Nick: No.
Interviewer: No? Now sometimes people have the feeling that someone or something outside of themselves are controlling their thoughts or their feelings – wondering if you’re having any experiences like that?
Nick: No, not like that.
Interviewer: So you haven’t had any feelings or impulses that seem to come from someone else not yourself?
Nick: No.
Interviewer: No?
Nick: No.
Interviewer: Okay. Do you ever have the feeling that um ideas or thoughts are put into your mind that aren’t yours?
Nick: No.
Interviewer: Okay. And what about the reverse process – having the the feeling that thoughts are being taken out of your head?
Nick: No, that’s never really happened.
Interviewer: Okay. Sometimes people feel that other people can read their minds or hear their thoughts. Does anything like that happen to you?
Nick: No.
Interviewer: No?
Nick: No.
Interviewer: Can you tell me, has anyone been giving you a hard time or trying to hurt you in any way?
Nick: Well yeah, I suppose that’s that’s been a big thing for me um It’s gotten really bad. I feel like that all the time. Umm, I’ve actually started a new apprenticeship about three months ago ahm, and my dad got me into it because ahh one of his mates is doing doing him – doing him a favour so he is taking me on, umm, and my dad’s an electrician and he wants me to come in and take over the family business so, so I feel that I have to do it but I really don’t want to be there and I really don’t think that I’m really good at being an electrician so, since I started work um I’ve I’ve really felt while I was at work that I was really bad at what I was doing, ahhm and I actually felt – I actually felt at the time, I was starting to feel that the guys at work were thinking um that I’m really bad at what I’m doing and that they’re laughing at me behind my back and talking about me behind my back, so um, I mean the the guys that I work with they’ve all got families and you know they go fishing together so they’re all a close group of friends um whereas I’ve got nothing in common with them. So whenever we go on smoko breaks they all talk with each other, um and I tend to smoke by myself because I’ve got nothing to say to them really and um when during the smoko breaks you know when they’re laughing, ahh when they’re talking sometimes they look over in my direction and I feel that they’re actually talking about me and they’re laughing at me and you know and they think that I’m really bad at what I do, ummm, and I I mean I’ve made quite a few mistakes at work, umm and and I feel that they’re just waiting for me to stuff up because they know they they I just think that they know that I’m going to stuff up.
Interviewer: So has this been going on the whole time you’ve been at work?
Nick: Well it is it was alright when I started, umm, and then a few weeks into it I I really started to get worried because I’d made a few small, small mistakes, I started to think that you know they really were thinking well you know who have we hired here – he doesn’t know what he is doing, um and that actually got really bad about a month ago. Um, we had a really important deadline that we had to meet and we were quite stressed and um everyone was really busy and I was quite anxious because, um it was just a stressful time during that time and it got really bad there where every time I was at work and every minute I was actually just looking over my shoulder and looking at ah the other workers and seeing if they were looking at me and if they were talking about me and I felt that they were waiting for me to stuff up and and um, so so it got bad about a month ago- it’s not as bad now-it’s still, it’s still pretty bad but it’s not as bad as what it was about a month ago.
Interviewer: Ahuh, so in what way is it a bit better now, then it was a month ago?
Nick: Well I suppose back then it was a really stressful period um and everyone was busy at work and I was really stressed at work so I think it got worse around that time ahh but I suppose now it’s it’s a bit less stressful at work and not so busy so, it’s not as bad but I still look around and I still feel that as if they’re talking about me as if I’m really bad, they think that I’m really bad at my job.
Interviewer: Uhuh. How does, how do you respond to this? Has it made you do anything differently or?
Nick: Um, well, I’m, I’m always really nervous about going to work and and I hate going to work now, um, and I I don’t really do anything differently, ah, but, I’m always looking and and listening and and um trying tryna catch them out- trying to catch them talking about me, um.
Interviewer: Do you -Have you been getting to work every day?
Nick: Well, the past, the past few months I’ve, I’ve taken a few days off. Well I’ve been taking nearly one day off a week um, which has been really good, um.
Interviewer: That’s what I’m wondering about. What’s it like for you when you’re at home?
Nick: Oh, when I have the days off and and when I’m home I’m fine you know. I don’t think about work and um I don’t worry about what they’re thinking of me and a lot of the times when I get home from work and I think about what’s happened earlier in the day you know, I feel that it’s – you know what I was thinking at the time was pretty, you know ,pretty silly and you know, it was, like they care what I’m doing and how good I am um.
Interviewer: So you can see it differently when you are at home?
Nick: Yeah, when I’m at home I’m I’m less worried about it and and, you know, sometimes I think that what I was thinking was pretty silly at the time but then when I’m at work I’m I get really anxious and worried about it.
Interviewer: Okay so you’re having this really hard time at work and things are okay at home.
Nick: Hmm, yeah.
Interviewer: You had these, this sort of stuff happen to you anywhere else or is it just at work?
Nick: Aww not really anywhere else. There’s there was this time um, it was about a month ago, still during that period.
Interviewer: During that time-
Nick: Yeah there was a couple of times um when I was actually on the train on my way to work and I was really tired and really really stressed and I just didn’t want to go to work, um and I was just standing up on the train and um I saw a couple talking to each other and I saw another guy um start laughing and um I I started to think at the time that um, they were actually talking about me and and they were laughing about me and um I was, I was starting to to think they thought I was really bad at what I was doing; they, they knew that I was a bad electrician and I was really bad at what I was doing, so I got really anxious and really worried about that and really stressed; um and that that happened for, for two days.
Interviewer: Two days..
Nic: That happened twice. Yeah.
Interviewer: Yep. And what happened when the journey ended and you got off the train and you were away from those people. Where you still-did you still have those worries?
Nick: Well, I I was really umn stressed getting off the train, um, and then you know, as I was walking to work I was sort of thinking about it a bit and– you know, I was thinking you know, those people don’t even know me and I’ve never met em before and they don’t even know what I do, so you know I was starting to think you know how would they know that I’m bad at what I do, so I started to think that you know maybe what I was thinking was a bit, you know, a bit over the top, a bit stupid, but you know at the time I really was convinced that they were.
Interviewer: It sounds like a really hard time and then you got to work and the worries would have come again.
Nick: Yeah yeah, like, like on those days walking to work I sort of cleared my head a bit and you know thought that it was all pretty stupid and then I got to work and you know, when work started again and the guys came in to work and you know, again, I still started to sort of worry about what they were thinking and yeah.
Interviewer: Okay, so you’re using, um, marijuana with your friends on the weekends.
Nick: Yeah.
Interviewer: How are you feeling when you’re, when you’re stoned with your friends?
Nick: Oh, um it feels pretty good. I mean the reason I do it is is to relax um.
Interviewer: And that’s the effect that it has?
Nick: Yeah, yeah. I don’t, I just do it just to get away from things, and not to think about things or anything like that so.
Interviewer: Some people find that when they use marijuana they get more worried but that doesn’t sound like your experience?
Nick: Ah no, no never, never been worried or nervous or stressed when I’ve been with my mates and smoking so I suppose that’s why I do it with them, just to chill out on the weekends.
Interviewer: Mkay. Have you been feeling that you’re especially important in some way or that you’ve got special powers to do things?
Nick: No. Not really. No that hasn’t happened.
Interviewer: Okay. Now have you been feeling that there’s anything odd going on with your body that you can’t explain?
Nick: No.
Interviewer: Or that your body’s changed in any way?
Nick: No.
Interviewer: No?um, what about feeling guilty or that you deserve punishment. Does that come up for you at all with..
Nick: No. No.
Interviewer: With these things? Okay, fine.
Nick: Some-Sometimes at work I feel that, um, just with,ah with my stuff ups I think that, you know, the boss will, will catch me out and he’ll find me out and um that I will get punished but yeah I don’t actually feel the need that I need to be punished or anything like that.
Interviewer: Are you very religious Nick, have you had any religious experiences?
Nick: Ahh, no, not really.
Interviewer: Okay. And um, do you have a girlfriend?
Nick: Ah, I I used to a couple of years ago but I can’t be bothered looking after one at the moment.
Interviewer: Another area that I need to ask you about is the area of ah perceptions, what you see and hear
Nick: Yeah
Interviewer: And that kind of thing. Um so I’m wondering if you’ve noticed any changes in in your vision, do you, um are things looking different to you?
Nick: NarI needed, I needed glasses. I need to get glasses, um so um things were getting a bit blurry um, but.
Interviewer: So glasses have improved your vision?
Nick: Yeah. Yeah.
Interviewer: In more recent times has there been a change in the way things look to you?
Nick: No
Interviewer: The colours brighter?
Nick: No, no that’s all the same
Interviewer: Anything like that
Nick: Yeah
Interviewer: Um. Okay. And what about um hearing things. Have you been hearing things that other people can’t hear?
Nick: No.
Interviewer: Any changes to the way you perceive sound at all?
Nick: No. No.
Interviewer: Any strange sensations in smell, smelling strange things, or things smelling different?
Nick: No.
Interviewer: And, um, I asked you whether you had any strange sensations on your skin. Whether you’ve um felt things crawling on your skin or underneath your skin?
Nick: No.
Interviewer: Anything like that?
Nick: No. No.
Interviewer: No. And what about your ability to communicate with people Nick? Have you felt like um, you’re able to communicate clearly, that people understand what you’re saying? You’re able –
Nick: Yeah.
Interviewer: to get your message across?
Nick: Yeah, never really had problems with that.
Interviewer: Uhuh.
Nick: No.
Interviewer: Okay. Do you have um trouble finding the correct word to use at all?
Nick: Aw, sometimes, I mean I’m I’m not the best at English so sometimes I, you know I can’t find the right – I’m thinking of the word that I’d use or I heard a couple of days ago and I just can’t think of it at the time, um, I think of it later on sometimes but- so sometimes I find- have trouble finding the right word, but, it doesn’t happen very often.
Interviewer: It doesn’t happen very often, it’s not something that you’re really worried about?
Nick: No.
Interviewer: No?
Nick: No.
Interviewer: Okay.
Nick: I still, they still understand what I’m trying to say.
Interviewer: Yep. Do you ever have the feeling that, um, you go off on tangents and that people don’t follow what you’re on about?
Nick: No.
Interviewer: No? So do you think your activity level has dropped off a bit? Are there things you used to do that you don’t do now?
Nick: Well, I, I mean I always used to go out with my friends. Go out drinking. Go out clubbing and go to the gym with them, um but, since, since work has started I really haven’t been in the mood to do anything like that. So I haven’t been in the mood to go out with them.
Interviewer: So does that mean you’re not going out at all now?
Nick: Oh, sometimes they drag me out like a lot of the times I don’t want to go but sometimes they just drag me out, and when we actually go out I have a great time with them. So it’s like, it’s like nothing.
Interviewer: So you are still able to enjoy yourself at times but-
Nick: Yeah.
Interviewer: But it’s a bit hard to get yourself going?
Nick: Yeah, yeah. I just feel I don’t have the energy and just don’t want to do it anymore.
The DVD is paused. Take each of the 4 subscales and rate the Global Assessment and Frequency and Duration for each. Press Continue and the answers will follow.
UNUSUAL THOUGHT CONTENT – GLOBAL RATING SCALE
| 0Never,absent | 1Questionable | 2Mild | 3Moderate | 4Moderately severe | 5Severe | 6Psychotic and Severe |
| NoUnusualContent. | Mildelaboration of conventionalbeliefs as held by aproportion of the population. | Vague sense that something is different or not quite right with the world, a sense that things have changed but not able to be clearly articulated. Subject not concerned/worried about this experience. | A feeling of perplexity, a stronger sense of uncertainty regarding thoughts than 2. | Referential ideas that certain events, object or people have a particular and unusual significance. Feeling thatexperience may be coming from outside the self. Belief not held with conviction, subject able to question.Does not result in change of behavior. | Unusual thoughts that contain completely original and highly improbable material.Subject can doubt (not held with delusion conviction) or which the subject does not believe all the time.May result in some change in behavior, but minor. | Unusual thoughts containing original and highly improbable material held with delusional conviction (no doubt).May have marked impact on behavior. |
Alison Yung: Unusual thought content. Nick receives a zero for unusual thought content as he does not answer positively to any of the questions.
Non-Bizarre ideas. He does rate on the Non-Bizarre ideas sub-scale however because of the experiences he has been having at work lately. He receives a Global score of 5 with his persecutory ideas – feelings that other people know that he is bad at his job. As he has experienced these thoughts about strangers on the train it is highly unlikely that they are true. However these thoughts are not held with delusional conviction as he is able to question these thoughts. Thus the intensity is not as high as a score of 6. These thoughts have resulted in Nick taking some time off work. Hence they have resulted in some change in behavior. They are not very easy for Nick to dismiss which means that the intensity is not as low as a score of 3.
Because these thoughts occur most days when he is at work. and last for more than an hour he rates a frequency and duration score of 4.
Frequency and Duration
| 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| Absent | Less than once a month | Once a month to twice a week – less than one hour per occasion | Once a month to twice a week – more than one hour per occasionOR3 to 6 times a week – less than one hour per occasion | 3 to 6 times a week – morethan an hour per occasionORdaily – less than an hour per occ. | Daily – morethan an hour per occ.ORseveral times a day | Continuous |
Pattern of Symptoms
| 0 | 1 | 2 |
| No relation to substance use noted | Occurs in relation to substance use and at other times as well | Noted only in relation to substance use |
Level of Distress (In Relation to Symptoms)
| 0 | 100 |
Not At All Distressed Extremely Distressed
Perceptual Abnormalities – Global Rating Scale
| 0Never,absent | 1Questionable | 2Mild | 3Moderate | 4Moderately severe | 5Psychotic but not severe | 6Psychotic and severe |
| No abnormal perceptual experience | Heightened or dulled perceptions, distortions, illusions (e.g. lights/shadows).Not particularly distressing.Hypnogogic/hypnopompic experiences. | More puzzling experiences, more intense/vivid distortions/illusions, indistinct murmuring, etc.Subject unsure of nature of experiences. Able to dismiss. Not distressing.Derealisation/depersonalisation | Much clearer experience than 3, such as name being called, hearing phone ringing etc, but may be fleeting/transient. Able to give plausible explanation for experience. May be associated with some distress. | True hallucinations, i.e. hearing voices or conversation, feeling something touching body. Subject able to question experience with effort.May be frightening or associated with some distress. | True hallucinations which the subject believes are true at the time of, and after , experiencing them. May be very distressing |
Perceptual Abnormalities – Nick states that he needed glasses. However, he does not report experiencing any perceptual abnormalities so for this sub-scale he rates a zero.
Disorganised Speech – Global Rating Scale
| 0Never,absent | 1Question able | 2Mild | 3Moderate | 4Moderately severe | 5Severe | 6Psychotic |
| Normal logical speech, no disorganization, no problems communicating or being understood. | Slight subjective difficulties, eg problems getting message across. Not noticeable by others. | Somewhat vague, some evidence of circumstantiality or irrelevance in speech. Feeling of not being understood. | Clear evidence of mild disconnected speech and thought patterns. Links between ideas rather tangential. Increased feeling of frustration in conversation. | Marked circumstantiality or tangentiality in speech, but responds to structuring in interview. May have to resort to gesture, or mime to communicate. | Lack of coherence, unintelligible speech, significant difficulty following line of thought. Loose associations in speech. |
Disorganised speech – Nick reports that he sometimes has trouble finding the correct word at the right time. However people still understand what he is saying so he rates a global score of 2 for disorganized speech. He said that this does not happen very often so he rates a frequency and duration score of 1.
Nick meets the PACE intake criteria for Group 2, the Attenuated Psychosis group. He also meets the drop in functioning criteria.
Note: Nick is played by an actor, however the interviewer is a doctor employed by Orygen Youth Health
[1] Orygen Youth Health Centre, 2009, “Comprehensive Assessment of At Risk Mental State (CAARMS) Training DVD”, The PACE Clinic, Department of Psychiatry, University of Melbourne. see http://www.eppic.org.au/risk-mental-state accessed 3 September 2012
[2] McGorry P. Right of Reply – Patrick McGorry on Early Intervention for Psychosis. December 11, 2010. http://speedupsitstill.com/reply-patrick-mcgorry-early-intervention-psychosis#more-1075
[3] Professor McGorry wrote “the false positive rate (for UHR) may exceed 50-60%” McGorry P.D. ‘Is early intervention in the major psychiatric disorders justified? Yes’, BMJ 2008;337:a695 http://www.bmj.com/cgi/content/full/337/aug04_1/a695 (accessed 3 August 2010) Professor McGorry’s close colleague Alison Yung identified the conversion rate from UHR to first episode psychosis was 36% in an article in the Medical Journal of Australia titled Is it appropriate to treat people at high-risk of psychosis before first onset — Yes Available at https://www.mja.com.au/journal/2012/196/9/it-appropriate-treat-people-high-risk-psychosis-first-onset-yes
[4] Professor David Castle, Medical Journal of Australia, 21 May 2012, Is it appropriate to treat people at high-risk of psychosis before first onset — No Available at https://www.mja.com.au/journal/2012/196/9/it-appropriate-treat-people-high-risk-psychosis-first-onset-no
Tags: Alison Yung, attenuated psychosis, EPPIC, is nick sick, Jon Jureidini, Martin Whitely, Orygen Youth Health, Patrick McGorry, Psychosis Risk Syndrome, ultra high risk
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The young man should change jobs and do something that he likes. How scary that being pressured into a job that his father wants him to do that is obviously causing the unhappiness could result in him getting a psychiatric label and even worse being put on some dangerous medication. Any decent career advisor could help this young man eradicate the source of his unhappiness – a job he hates that he is doing only to please his father. No psychiatrist needed.
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totally accurate. Looks like psychaitrists are desperate to find some more patients here, when one has to go to the low levels that have happened here, one thinks they need to find a new job!
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Agreed, the one comment I forgot to make in my commentary was that Nick didn,t need a mental health assessment he needed career guidance.
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If I am to take this seriously I have been at Ultra High Risk of Psychosis my whole life. I have had concerns about this definition in the past, but to find out the reality of how it is being used, and how people are being diagnosed is even worse than I first expected. I cannot believe that they seriously believe in this stuff, that they use this as a form of training and that they promote it around the world. What ever happened to common sense and looking at reality and what is really going on for a person.
I was bullied relentlessly as a child. Due to the level of the bullying I suffered and the fact that most in the school were aware of it, when I was in my first year of primary school, the primary bullies, who had physically assulted me to forced to apologise to me individually in front of the whole school. They were stood up on the stage, and I was walked along in front of them, for them to individually apologise to me. The reality is that if the school did not know who I was before then, they did then. I know they believed they did the right thing by me, but what it made me think and feel was not good. Since then I have always been paranoid that people are talking about me. But I am also ALWAYS able to put it into reality. But according to this it does not matter.
Like Martin I have also had jobs that I was bad at, and at times I did actually hear people talking about me. I lost my sight in recent years and now use a Guide Dog, and believe me I do hear people talking about me in public places, and that is not me hearing voices it is very real. Strange how walking in a public place with a dog does that to you. But if I am to take this seriously a stranger would never talk about someone in a public place – the fact of the matter is they do. And I am sure we have all had experiences of commenting to someone about something a person is wearing or doing in a public place that we did not know.
As for not being able to find the words I want for something, well that is also something I experience on a very regular, if not daily basis.
People on the Autism Spectrum regularly experience very different sensory experiences. They do feel things and hear things, and see things that disturb them more than the average person. If anything, many argue that ASD are simply sensory issues that manifest themselves in different ways. But here they see them as signs of psychosis!! I also wonder what would have happened if Nick had not already seen an optemotrist and gotten glasses. Would they have simply said that him not being able to see clearly was a sign of psychosis. It very much seems that way from this video.
The DSM does require ALL other medical or physical causes of something to be ruled out, yet in reality that never happens and it also not what medical students are being taught. They are now being taught to consider this stuff first, not last. How many people are being labelled as mentally ill, just because no one will suggest they see an optometrist?? How many people who are already labelled as mentally ill are being encouraged to have FULL health checks for everything, including seeing an optometrist, having a proper hearing test, etc, etc.
I could not agree more with Jon Jureidini in that there is one thing this does show and that is how NOT to do a psychiatric assessment of someone.
It is beyond me how politicans can be stupid enough to believe in this stuff. It is just as beyond me how anyone could even consider that Nick is at risk of anything or that he is even suffering from any mental health condition. What he is showing is perfectly normal behaviour and thinking. Don’t see them caring for one second about the father or what is going on at home. They don’t look at what is causing all of this stuff, which is pretty obvious to anyone with common sense. Instead they seriously believe it is all a brain disease!! The only ones with disturbed thinking here are those who believe in this crap.
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Professor Mcgorry has the support of all political parties in Canberra and to the best of my knowledge the independents not because they ‘believe in this stuff’ but because they don’t understand the detail of what is being proposed. In fairness to Canberra politicians they know something needs to be done about mental health and Patrick Mcgorry’s early intervention message seems plausible (until you look at the detail and the evidence).
In addition his status as Australian of the Year made him the ‘go to’ guy in the lead up to the 2010 federal election and no federal politician was prepared to challenge what he said as the media were also part of the cheer squad.
It is slowly happening with the media but nonetheless it is proving very difficult to get Canberra politicians interested in reviewing the evidence after they have made the decision.
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It is hard to believe that this sort of diagnostic category has achieved a level of legitimacy that warrants its own training video. The potential harm done to this young man through labeling and medicating is enormous, scientifically unjustified, and unconscionable. Will the pathologizing of typical human responses to emotional and cognitive distress never cease? Time to stop the disease-mongering justified by the DSM. Thanks for your work, Martin. Keep it up.
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Fortunately the American Psychiatric association was embarrassed into dropping Attentuated Psychosis Syndrome from the proposed DSM5 (and Prof McGorry belatedly agreed it should not be included). However, Prof McGorry’s Orygen Youth Health still provides training videos in how to diagnose it. He is on the record as saying misdiagnosis and overprescription of the UHR group is a problem outside services he controls but not in his services.
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How is it that they can consider that those displaying these supposed UHR symptoms can be acutely unwell, and that they require urgent mental health treatment for the symptoms they do display?? At most some family counselling is in order and some assistance to find a job/career that he will enjoy. As for the smoking of dope, well he is doing it as it relieves his stress which is caused by his father and a job he hates. Get rid of those problems and chances are he wont do it anymore.
What happened to the hypocratic oath of “first do no harm”. Clearly they do not think it applies to them.
Is it any wonder we have a mental health epidemic on our hands in this country if these are the people they are dragging into the system. And of course if you tell someone for long enough that they have a diseased brain, chances are they will believe it. We put them on drugs that make them feel like shit, they go back to the doctor as they can’t cope with them and are told it all part of the underlying disease, so they are put on higher doses and other medications are added to the equation. Then we have an acutely unwell person and no one can understand why. Perhaps it starts with seriously addressing what the underlying problems really were instead of diagnosing people with being normal human beings!!
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Thanks for posting this Martin. It shows clearly how easy it is to “diagnose” mental illness. Just think how easy it will be in three year olds!
This video also shows how far removed from reality some of the proponents of screening are. -
I really appreciate that this has been posted. I agree totally with all that has been said, but one part has been missed out. The labelling has risks, the medications has risks, but what they would propose to do and are doing, even without those things, namely Cognitive Behavioural Therapy (CBT) also has many risks.
CBT tells someone that they do not know how to think properly and basically teaches them how to think. How is it that this young man’s thinking is defective?? How is it that he someone needs to learn how to think properly?? What does it mean to someone to be told week after week after week by a mental health professional that they do not know how to think?? That everything they think is somehow defective? One wonders how they get so many of these young people to have life long problems, well they are beginning by using what many consider to be safe therapies, by telling them they do not know how to think?? Exactly what thinking would be correct for this young man? Telling him he is a brilliant electrician, even when he knows he is not? Telling him he must follow his fathers wishes, when the fact remains that one should be entitled to there own career choice. Telling him to reject the very good friends that he has simply because he smokes some dope with them sometimes, when he wants to burn off steam. If anything this therapy is going to cause him to smoke more dope, as it is telling him how useless he is and telling him he needs to spend the rest of his life doing something he hates. If that is not a reciepe for making someone suicidal, I do not know what is.
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The interview followed a very thorough format, seeking signs and symptoms of psychosis.
This is not my approach. His symptoms are mild symptoms from approximately 20 months of age. Schizoaffective disorder has an age range-of-origin mostly between 19 and 21 months, with paranoid thoughts and feelings toward the 19 month age of origin and the depression more toward the 21 months age of origin. I thought his depression was a little more pronounced than the obvious paranoid thoughts.
If he has a younger sibling less than three years younger, it would probably be 20 months younger.
Usually the first psychosis is precipitated by a separation or rejection by a “most important person” in the present — which precipitates a partial return to a separation from mother trauma in the first 24 months of life (schizophrenia in the first 18 months of life, sz-affective disorder 19 to 21 months, bipolar hypomania peaks at 22 months, and depression with psychotic features up to 24 months. Non-psychotic depression has its origin between 24 and 34 months). This young man experienced a separation from a lady friend, but we don’t know if that is what started this process.
Right now he is experiencing a rejection by his father who is pressuring him to become an electrician, and it is not something he wants to do. He has a lot of self condemnation and feels very badly that he is not good at electrical work. The peak age of origin of the most intense self blame, condemnation and suicidal depression is 26 months, but the symptoms of paranoia signify an origin in the schizoaffective age range-of-origin.
Presently his feelings of wanting to please his father but fear of not being able to do so, are having a very deleterious impact on him. This is comparable to the Expressed Emotion (EE) factor in GW Brown’s study of 339 post mental hospital patients, commissioned by the Medical Research Counsel of England.
While they recommend a low EE factor over a high EE factor, I consider that like a person who has cancer and wants to get rid of most of it. I recommend a zero EE factor brought about by a complete, total separation from original nuclear family — for a period of time, perhaps two or three years. I would explain the process to the patient and family, and use a simple enlightenment technique to find out what he should do in life. I would ask him to have the following programmed dream: Decide: I will have a dream about occupation, and the interpretation of the dream will tell me exactly what to do that will work out best. I will awaken at the end of the dream, remember it and write it down.
This simple technique will allow him to find his own direction, and one that will work out best.
The problem with above survey is that I suspect that the survey results all too likely would lead to medication, based on risk of developing a psychosis. I would instead work at getting out of his bind and away from family, back with friends and moving in the direction he would prefer to go. This should be a very easy task to prevent psychosis in this young man.
There is a video on the home page of drmckenzie.com that illustrates twelve precise parallels between PTSD from adult life and delayed PTSD from infancy (schizophrenia), and shows (via powerpoint) for the first time (in the first 8-minute segment) the derivation of the precursors of schizophrenia, the derivation of the negative symptoms and the derivation of the positive symptoms.
Clancy
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Even if we could predict woth 100% certanty who becomes ‘psychotic’ we first need to define exactly what ‘psychotic’ means. Is it a medical condition?
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As a psychiatrist, I have watched both segments of the Orygen training video and read the transcript. In my opinion, having had very long experience of people in this young man’s position, any psychiatrist who diagnosed him as “ultra-high risk of a psychotic disorder” is a dangerously incompetent psychiatrist. The diagnosis of an acute stress response in a vulnerable and exposed youth is crystal clear, as is the treatment, and it does NOT involve antipsychotic medication.
Work-related stress responses (Acute Situational Disorders) almost invariably involve paranoid ideas of exactly this type. Of course, the interviewer must run through the Schneiderian First Rank Symptoms and the standard list of perceptual abnormalities to be sure there was nothing more ominous happening, just as we do with all patients, but to then slot these symptoms into a diagnostic box which studiously ignores the situational factor is a perfect example of why psychiatry has such a bad name.
This problem arises just because psychiatric symptoms are so non-specific but, because the people who made this video don’t have a formal model of mental disorder to guide their practice, their teaching or their research, they are able to put them where they like in the remarkably elastic DSM system. Their decision to label this youth as “pre-psychotic” was driven by their determination to diagnose this condition regardless of the reality factors, i.e. it was an ideological decision, not scientific, and certainly not considerate.
Because psychiatry lacks a formal model of mental disorder, it is pre-scientific and this sort of malpractice can flourish, driven not by clinical imperatives but by the swift and certain manipulation of the media, the grants process and the political scene by a group of highly proficient self-publicists who are totally lacking any capacity for self-criticism and resolutely evade valid criticism by carefully selecting the venues at which they will appear.
If this youth had been put on antipsychotic drugs, he would have become fat, lethargic, withdrawn and miserable. He would have given up the job, avoided his friends and drifted further from his family. Eventually, he would have attempted suicide, at which point the psychiatrist who made the wrong diagnosis and gave the wrong treatment would have said “Aha, you see? I was right, he is seriously mentally ill.”
Modern psychiatry is pre-scientific. McGorry and his group know this because they know they do not have a model of mental disorder that justifies their claims to being able to make accurate prognostications. They assess all symptoms as prepsychotic but ignore the fact that the great majority are normal reactions to abnormal events, or normal responses in abnormal personalities. By removing the situational factor, they are able to deem perfectly comprehensible mental states as “early psychosis,” when any experienced psychiatrist free of ideological bias (and with an ounce of common sense) would know that yes, the symptoms are superficially prepsychotic but no, they are not dangerous. This happens because the rubbery DSM system is not based on a model of mental disorder and allows ideologues to exploit the symptoms to their advantage, and to the disadvantage of the “patient.”
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Thankyou for such an honest account and true representation of what is really going on. It is the first time any psychiatrist has said so honestly that Psychaitry is pre-scientific. And if they wanted to really help people they would look at what is really going on, rather than trying to label something as some fictional brain disease. And you are exactly right with what happens with Medications. The side effects of medications become proof that they have a brain disease. That doctors, who are supposed to be some of the most highly educated people in the country can believe in it is beyond me. I will give credit to the rest of the population, they just don’t know what is going on. Doctors and especially psychiatrists should know better.
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I thought the video is OKish as a learning material for medical students about interview skills and psychopathology as a learning material. I don’t think the clip should be used beyond this purpose. To conclude that this man’s mental state and experiences are indicative of UHR for psychosis, is an evidence “baseless” statement, and should be treated with caution. This is a completely manufactured and scripted scenario and interview. Indeed, the script is not even properly written as a real life one, as Nick, moved from simple answers of “No”, to then telling the doctor everything in his life! I wish my patients are half this forthcoming with their replies.
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I had another thought – Psychiatrists like this really negate the possibility of religion – God and spirits and all that – no matter the faith. This has existed for tens of thousands of years prior to psychiatric theories that negate all of this and make it into a psychiatric illness. They cannot explain something, so they just make up theories.
Imagine the religious people of ages past being assessed as psychotic because they talked with God and heard God talking in their heads. Moses, Ambraham – all of them.
Really! Jesus would be locked up in an involuntary psychiatric ward if he appeared in 2012 saying what is written in the Bible. So would Mohammad and what about Buddha – he would have been locked up and drugged for sitting under the tree for days on end, not eating. Labelled with some convoluted multi-worded label.
What about the people who do really hear people talking in their heads – psychics, clarivoyants and people who receive messages from dead people giving clues about the whereabouts of clues that help them advise the police to track down the killers. Many movies about this and stories.
Many people believe that there are spirits that exist – when a person dies they can feel and hear the presence still and the deceased person’s spirit communicates to them. How do we know they are not wrong? How can we judge and label them as mentally ill when there is no science to back it up.?
And some people experience their conscience “talking” to them. And guilty people definitely find more “voices” in their head in relation to their guilt that disappears when they come clean and stop keeping secrets.
Anyway just a thought.
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The difference appears to be if you can make a living out of listening to voices then it is all OK.
The last time I went to a church, the priest stood up the front and said “God was talking to me last night”. If I said the same thing to a psychatirst I would be locked up and forcibly medicated, but they accept it as normal when a priest or the like says it.
I personally know of a young person who got caught up in early psychosis programs in Victorai, not through Orygen, but standard mental health services, on the basis that their mother had been killed in a car accident and they went to see a clairvoient about it. They believed that someone else had spoken to there mother. They were put on forced treatment orders on that alone. Mind you they did not go and put a forced treatment order on the person who made a living out of talking to the dead. That was and is reserved for those who pay them for it.
EVERYONE has had the experience of hearing something and not being able to explain where the noise came from. While this is very different from those that do really hear voices, it is a start of it. The simple fact is that psychosis, as they define it is normal to some levels, just like depression is normal at some levels. They just define when it is and when it is not a brain disease. With depression that is 14 days. I guess that means I can feel sad for 13 days, 23 hours, 59 minutes and 59 seconds and it is perfectly normal. But as soon as I experience one more second of sadness I suddenly have a life long brain disease, and need mind numbing medication, that causes horrible side effects (including suicide) for it!!
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I find some of the comments by psychiatrists on here quite disturbing. They are clinging to the systems of their profession, using psychiatric diagnosis, dodgy explanations of so called schzo-affective disorder and so called schizophrenia and forms of clinical interviewing whereas the non professionals seem quite human, using everyday explanations and ideas like, the young man needs a careers counsellor.
All the research that I know of says that what people who are in distress need is a trusting relationship with someone who cares for them who then encourages them to deal with their problems. In counselling and therapy it has been found that the quality of the relationship, as assessed by the client, is more important than the school of therapy the professional espouses.
The professional language on some of the posts is, in my opinion, a power play to claim that the professional knows something that the rest of us do not, but to my mind the non-professionals seem more caring and understanding.
I would like to see a video where someone asks the young man if he would like a coffee and a bit of a chat. That might be much more educational than this rather disturbing interview
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I could not agree more. As a human who has accessed services I can say that people can and do open up to people on the first session, about what is important to them. It is about whether you are open to listening to what the individual has to say to you. It becomes very obvious to the person seeking help very early on whether the so called professional actually wants to listen and whether they care about you as a person, or whether they are only interested in professional power play and trying to convince you that you have a defective brain disease. Yet all you here from professionals is that our so called brain diseases mean that we have no idea of the fact that we need help and that we refuse treatment. I have personally met people who are very very very acutely unwell and ALL of them wanted help. I have never met and I do not believe I ever will meet a person who is unwell emotionally who does not want help. On the other hand I can unfortunately count on one hand the numbers of people who were happy with the help they were currently recieving, or even remotly happy with the so called professionals who were supposed to be working with them. But rather than look internally and say, why is it that these people are not opening up to me, why do they seek help and then not come back again, is there something I can do differently, or should I be referring them to someone else, they simply blame the client and some fictional disese. As you have made so clear what is important is not what shcool of therapy they come from but the humanness of the person offering the support.
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The interviewer is just not listening to him. Nick seems to be an straightforward young man who has identified what his issues are. There is no indication that he will be supported to address his sadness and anxiety at work. This diagnosis is scary, and psycjiatric labels are very sticky
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Yes its very worrying that someone like nick can be Labled with a mental health disorder and put on psychotic medication. Who is the all high and mighty one playing god here making up the selection criteria. Funny I should say that, the church has been loosing its influence of late, where is god in all this. Maybe the DSM is the new bible and psychiatrists are the new disciples.
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I fear for the children of Australia!
If this is the sort of screening used on a young man, is the screening of three year olds also of such poor quality?
For example if a three year old is agitated or moody or excited or shy will they be labelled at risk? Also my GP told me that if such a screening indicated risk the parent has to be told. This could lead to a detrimental effect on the parent child relationship. The parent could become hypersensitive to their childs behaviour or feeling that their child is limited. Hypersensitivity could see this parent racing to the doctor for intervention over situations that simply need love and support. Some parents may feel ill will toward their child or in the worse case scenario become aggressive or distant. Some parents may attempt to “fix” the child with dubious rules and regulations. Some parents will sigh in relief as they abdicate all of the responsibility of guiding their child emotionally and spiritually, in my opinion this is already rampant with young children having computers and TVs in their rooms and therefore little family communication.
The attempt to make the screening of three year olds linked to Family tax benefit (i.e. loss of benefit if the child is not screened) failed but the proponents will I believe keep on pushing for some form of compulsion.
Also disturbing is that when I first heard about this mental health screening of three year olds I visited a lot of parenting forums online. My thought was that there would be outrage, after all this would be the place to find concerned, proactive parents right? What I actually found was majority support of the screening. -
Martin if you are still listening, can you get some details about the three year old screening? What constitutes “at risk” for them. My GP said she is very well able to identify autism signs without it but would not elaborate more on what will be assessed.
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