Thursday, July 28, 2016

Psychiatry, Confirmation Bias, and the Scientific Method: A Case Study

Like most people who enjoy studying psychology, I used to have very strong faith in psychiatry. Then I experienced what psychiatric treatment for a serious mental illness can actually be like, and now I'm not nearly so sure it's even a science. Neurology is definitely a science, but psychiatry without neurology is more of a guessing game. My bipolar diagnosis came from a well-respected psychiatrist who literally refused to use the scientific method, which is why I doubted it from the very beginning. Turns out, it was bogus. I'm going to explain how I figured this out, in the hope this information will help others.

A little background about me: Besides studying psychology, I have long identified as a psychonaut. This is a term used mainly in psychedelic and chaos magical circles, to denote a person who enjoys tripping for personal growth, mysticism, or both. You might think of psychonautics as occupying a space midway between psychiatry and shamanism: the goals are pretty much the same, but the substances and methods are a bit different from either one.

All this is only relevant in two ways: I know more than the average layperson about brain chemistry, and when I trip, I write down insights and recollections for later analysis. I learned the latter practice from the writings of Aldous Huxley and John C. Lilly. So when I had manic episodes, I treated them as extended trips. Not only did I write down everything I remembered, but I was also able to get my psych papers from jail and the mental hospital. (The first manic episode included being arrested for disorderly conduct.) What I actually had were probably more like mystical experiences with psychotic features, but that's only vaguely relevant to this post.

This is where it gets more interesting. I discovered that the psychiatrist at the jail lied and said I smelled of alcohol when I arrived. I am not a drinker, and I have clear memories of what I did and didn't consume. But I was in rural Pennsylvania, where they likely had very little knowledge of what a tripping person looks like... so they lied and said I was a drunk. Not really a big deal, but weird and a little creepy.

I stuck with my current psychiatrist (we'll call him Dr. A) after that first episode, but we decided I should stop taking Strattera. I had once been manic on it before when I was taking way too high of a dose, and I had been taking it along with Wellbutrin (whose effects it magnifies). I switched to taking Wellbutrin by itself and things were good for a while. Then the second manic episode happened, and afterwards I decided to switch to a new psychiatrist ("Dr. B") who my therapist often works with. We agreed that I shouldn't take any of the things I was taking when the manic episodes happened, so there went the Wellbutrin. This left me taking the lithium and haldol the hospital had prescribed, which Dr. B felt were appropriate. I had terrible sleepiness and hand cramps from the haldol, though, so he switched me to risperdal. So far, so good.

But then came the confirmation bias and refusal to use the scientific method. I came in with a great deal of information, much of which he ignored, even though it was relevant:

1. I have only ever had manic episodes when I was either on Prozac, Effexor, Wellbutrin, or Strattera. These are all reuptake inhibitors for various neurotransmitters that affect mood and attention  (serotonin, dopamine, and/or norepinephrine).

2. I have only ever had exogenous depression, the kind caused by bad things that happened to me. While I was very depressed in high school, it was because I was unpopular, in the closet, and a moody teenager with a mother who pretty much refused to let me be an introvert. When I got out of the hospital, I was depressed because my life had pretty much imploded, and I had lost my full-time tech support business and had to get a day job. I do not enjoy being an employee.

3. I require AD/HD medication in order to be able to focus on work. That's what the Wellbutrin and Strattera were for. I don't like the way Ritalin and Adderall give me the jitters, make my heart race, and make me sleepy when they wear off. They are not a good idea for people with anxiety.

4. I smoke pot not just because it's fun, but because it helps with my anxiety also. Never been much of a drinker, like I said above, and honestly marijuana is less harmful than alcohol anyway.

The only pieces of information he was willing to act on were these:

1. I had two manic episodes in the same year.

2. He had never treated anyone with both bipolar disorder and AD/HD before.

3. He had only ever prescribed Ritalin or Adderall for AD/HD in the past.

4. Bipolar people often refuse to take their medication.

5. My uncle was bipolar and had recently committed suicide.

6. Bipolar  can sometimes remember things incorrectly, if the memories are from when they were manic or depressed.

Since I had had two manic episodes, and was refusing to take my medication, that meant I must be bipolar. He even uttered the words "if you respond to lithium, that means you have the disorder". Early on, we had a conversation about how I was not convinced bipolar was the right diagnosis, because all my manic episodes had had psych meds and/or psychedelics involved. He agreed with me that after perhaps a year, I could go off the lithium and risperdal to test (scientifically!) whether or not I could ever have a manic episode in a vacuum. Later he claimed this conversation had not occurred, and that either I was twisting his words or that I led him to say something he didn't mean. Also, I had to stop smoking pot because it would obviously unbalance me and cause mania. The study I found saying that bipolar people who take lithium and smoke pot have better scores on brain function tests than ones who take lithium by itself "doesn't count" because I found it on the internet. Nevermind that it was published in a peer-reviewed journal also. And my lack of desire to take a medication that could eventually put me into kidney failure was just another symptom of my bipolar disorder.

My logic teacher used to call this last bit a self-sealing argument. Any criticism of the argument is interpreted as proof the argument is true. It's maddening.

He also refused to prescribe me anything for my attention, despite the fact that I repeatedly told him I needed it for work. I don't think he actually believed in adult AD/HD at all. When he finally came around on this issue, he told me he was only willing to prescribe Ritalin or Adderall because he had prescribed them before. Even though they were much more likely to cause mania in a bipolar person, he would not give me the modafinil I asked for, preferring to have me come in WEEKLY to check for mania from the meds I specifically told him I did not want. And in order to get even those, I had to stop taking "the soup" (his words) of nootropics I was taking on my own to try to mitigate the AD/HD somewhat. This was the last straw that caused me to go back to Dr. A. He isn't perfect either, and probably a little too laissez-faire, but at least he listens to me and doesn't pull any of this authoritarian, manipulative gaslighting bullshit I had to deal with from Dr. B.

Fast-forward to now. I have been smoking pot regularly for two years, and not taking the lithium or the risperdal for over a year. Modafinil has been every bit as great as I hoped it would be. There has not been a single hiccup. Every time I check myself or ask someone to check my behavior for signs of mania, it turns out that I'm just happy or excited in a completely normal way. Smoke without fire, in other words. I don't have manic episode without the influence of SSRIs, SNRIs, and/or strong psychedelics, and I have always known this to be the case. But when you are a hammer, everyone else looks like a nail. And Dr. B has been a hammer for a long, long time.

Let me be clear: I am not a typical patient. I do lots of research and I am very assertive. I'm the son of a school counselor, and always have read psychological research on my own. I've explored altered states of consciousness enough to know how my own mind works. (I might have stayed manic for months, rather than a week and a half each time, if not for this. The doctors were surprised how quickly I came out of it.) And I tested most of the factors in my first manic episode individually (legal drugs, psychedelics, sleep deprivation, immersive live-action role-playing games,) to ensure they weren't dangerous by themselves. I left out only the ones (ayahuasca, underworld journeying) that I have no intention of trying again (or at least, not any time soon).

But I still feel that everyone should always remember the doctor-patient relationship is about trust and referred power. If you don't trust someone, then you shouldn't be willing to give them power over you. And if they don't listen to your input, there is no reason you should trust them. Doctors are fallible human beings just like everyone else. And there is never any shame in getting a second opinion. Don't let anyone tell you that you're "just shopping for a doctor who will give you a diagnosis you like better". (Unless it's true, of course. Don't do that.)

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