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Perspectives on Psychiatric Diagnosis

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by Eric M. Plakun, MD, Associate Medical Director/Director of Biopsychosocial Advocacy

Eric M. Plakun, MD, DLFAPA, FACPsych, Associate Medical Director and Director of Biopsychosocial AdvocacyOur research indicates that people in treatment at the Austen Riggs Center on average meet criteria for six different simultaneous [so-called “comorbid”] DSM-5 disorders: 

  • About 85% of our patients meet criteria for depression—either a major depressive disorder, persistent depressive disorder, or bipolar depression, and nearly 90% of these also meet criteria for a personality disorder, most often borderline personality disorder
  • Just under half meet criteria for a substance use disorder. 
  • Approximately 60% have experienced significant early life adversity, including loss, deprivation, neglect, psychological trauma, or abuse.
  • Nearly a third meet criteria for post-traumatic stress disorder (PTSD). 
  • About 15-20% meet criteria for eating disorders and/or anxiety disorders, obsessive compulsive disorder (OCD), psychotic spectrum disorders like schizophrenia, schizoaffective disorder, or bipolar disorder with psychosis.
  • Some meet criteria for autism spectrum disorders or learning disorders. 

The field is learning that psychiatric diagnosis is not as straightforward as in the rest of medicine and surgery, where making the single right diagnosis points toward the likely effective treatment. For example, large studies of depression like the STAR*D show that more than 75% of people who present with depression have other comorbid disorders and are less likely to tolerate or respond to treatments that have been tested for efficacy on carefully-selected samples of people with depression who do not have comorbid disorders. There is good evidence that those with comorbid depression, especially those with personality disorders and early adversity, respond optimally to treatments that include both medication and individual therapy, including psychodynamic psychotherapy.

In the field’s terminology, people who fail to respond to two evidence-based treatments for depression—as many of our depressed people have—are characterized as “treatment resistant.” It is our contention that the “resistance” in treatment resistance is not generally located in the depressed person, but instead reflects the limitation of treatment approaches that rely too narrowly on medications developed and tested in samples of depressed people who do not have other comorbid disorders with depression. Treatment resistance is found in depression and other mood disorders like bipolar disorder, but also in anxiety disorders, schizophrenia, and others. Borderline personality disorder, in particular, has been shown to “robustly predict the persistence” of major depression treated with antidepressant medications, so also treating borderline personality disorder with therapy is an essential part of treating depression. 

The therapeutic approach at Riggs includes much more than medications alone—adding intensive individual therapy, immersion in a therapeutic community, family and group treatment—in an integrated, personalized treatment program.Several Riggs staff members have national reputations for working with treatment-resistant disorders, especially depression. They are often invited to teach and write about the importance of attending to comorbidity (especially personality disorder comorbidity), early adverse experiences, and the unique life story of each patient [psychiatry’s form of “personalized medicine”] in work with people who do not respond adequately to usual first line treatments. This is why our therapeutic approach at Riggs includes much more than medications alone—adding intensive individual therapy, immersion in a therapeutic community, family and group treatment—in an integrated, personalized treatment program that maximizes a person’s chance to find their resilience and reclaim their ability to function.

Emerging research in the field supports our approach. As noted, many more people seeking treatment have multiple comorbid disorders than we suspected, and this comorbidity increases the risk of so-called treatment resistance, which warrants a more comprehensive approach than outpatient treatment alone. Similarly, we are learning that early adverse experiences are profoundly important in contributing to the likelihood of mental disorders of all kinds, not just PTSD, as well as to the likelihood of medical disorders. Although medications like antidepressants are often effective, we are learning that they are less effective than we believed when all studies – including those not published – are included in data analyses; they frequently do not show drug superiority to placebo in randomized trials. 

The combination of therapy and medication has been shown to be more powerful than either one alone in multiple studies of a range of disorders from depression to schizophrenia. Important efforts to find the genes for disorders like depression or schizophrenia are teaching us that the inheritance of these disorders is highly complex and it is not genes or biology alone that cause mental disorders, but “gene-by-environment interactions.” All this evidence indicates that it makes sense to include a psychotherapeutic engagement of environmental contributions to disorders as part of treatment. 

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