14 clinicians with mental illness share how they ask patients about mania, depression, psychosis, OCD, panic disorder, addiction, trauma, and suicide.

Publication Date: 04/29/2024

Duration: 19 minutes, 54 seconds

KELLIE NEWSOME: Psychiatric disorders don’t always look the way they are spelled out in the DSM. Today, we hear from clinicians who have lived with psychiatric disorders on how to sharpen our interviewing skills.

CHRIS AIKEN: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report.

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. In the mid 1980’s, Kay Redfield Jamison gathered all the courage she could muster to tell her department chair that she had manic depressive illness. The place was Johns Hopkins University, where Dr. Jamison worked as a psychologist in the psychiatry department. The chair – Paul McHugh – did not respond as she expected:

CHRIS AIKEN: “Kay, dear, I know you have manic-depressive illness.” He paused, and then laughed. “If we got rid of all of the manic-depressives on the medical school faculty, not only would we have a much smaller faculty, it would also be a far more boring one.”

KELLIE NEWSOME: Dr. Jamison later came out to the world through her 1995 bestseller, An Unquiet Mind. Her brave steps were followed by Steve Hayes, who developed Acceptance and Commitment Therapy in part to treat his own panic disorder, and Marsha Linehan, who disclosed her own history of borderline personality disorder, suicidality, and long-term hospitalizations to the New York Times in 2011. In this episode, we’re going to hear from people working in the field who have lived with psychiatric disorders of all kinds. Some in recovery, some still in the struggle.

CHRIS AIKEN: The people who reached out to us were a select group: Self aware enough to get help, and open enough to share. But the problems they lived with were not mild. Half reported inpatient stays, psychotic episodes, or work related disability. One had a vagal nerve stimulator for depression, and two credited ECT with saving their lives. Among our 14 interviewees were 5 psychiatrists, 5 psychiatric NPs, 2 psychiatric PAs, and RN and a therapist.

We’ll bring you insights from these interviews in this Wounded Healers series.

KELLIE NEWSOME: I really wish we had another word besides “Wounded Healers” – it makes it sound like we’re all frail little birds hobbling around on one leg, caring for other people instead of ourselves, or even condescending like we have some kind of special magnanimous power.

CHRIS AIKEN: Yea like it’s exaggerated on both sides – you’re broken and you have a superpower. Sorry. I couldn’t think of a better word, and I couldn’t think of any one word that fit with all the viewpoints we heard from. So we put the title in parentheses. 

There were some common themes in these interviews, but a lot of differences. Some wanted their name withheld, and some wanted it disclosed in the hope that doing so would bring down stigma. But I remember a patient who came out about having bipolar disorder in an interview with her local newspaper. Later, she came to regret it due to effects on her career, but once that genie was out on the internet she couldn’t put it back in the bottle. So I’ve decided to withhold all names in this podcast.

These interviews changed me in a lot of ways, like how I speak with patients. Living with a psychiatric illness gives people a richer language to talk about it, and a sharper intuition for picking up on it. They understand how bad things can get, and resist the temptation to minimize problems even when patients lead us that way…

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CHRIS AIKEN: One psychiatrist spoke of a “cheat code” he uses to get to the heart of the matter with patients….

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KELLIE NEWSOME: These providers had an understanding of psychiatric symptoms that went a little deeper than the DSM

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KELLIE NEWSOME: Clinicians with bipolar disorder were particularly vivid in their descriptions of manic symptoms

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CHRIS AIKEN: In the 1970’s, researchers went into the psychiatric wards and asked patients who were hospitalized for mania what brought them there. “Depression,” was the most common answer. In my own practice I rarely see euphoric mania – it does exist, but it tends to last a few days at most before it turns into an impatient, irritable, anxious or even mixed state. 

KELLIE NEWSOME: Let’s pause for a preview of the CME quiz for this episode. Earn CME for this podcast through the link in the show notes, or click on Podcast under the multimedia link on the Carlat Report website.

1. Which anxiety symptom is particularly resonant with Panic Disorder, according to our interviews with clinicians who have lived experience?

A. Free floating anxiety

B. Spontaneous, uncued attacks

C. Feeling of impending doom

D. Palpitations

KELLIE NEWSOME: The DSM doesn’t always paint a clear portrait of the disorders it describes, because it focuses on symptoms that are specific to the illness – the ones that separate it statistically from other disorders – rather than the symptoms that are most common. The people I see with depression are much more likely to complain of anxiety than a low appetite, but anxiety isn’t in the DSM list because it’s shared by so many disorders. One provider spoke further of the hidden symptoms of depression…

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KELLIE NEWSOME: For a clinician with schizoaffective disorder, all 3 phases of the illness were felt physically

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CHRIS AIKEN: As Kellie said, anxiety is one of the most common symptoms in psychiatry and one of the most overused. When a patient use the word “anxiety” it can bias us toward an anxiety diagnoses, even though they may be talking about paranoia, obsessions, phobia, or the uncomfortably elevated energy of a mixed state. I’ll never forget the time I misdiagnosed a patient with social anxiety disorder when he was really having negative symptoms of schizophrenia – not something I’m proud of. To avoid that bias, I’ll often substitute the word “anxiety” with “distress” in my head – there are no “anti-distress” meds, so doing that helps me avoid reflexively reaching for an anti-anxiety med like a benzo. 

KELLIE NEWSOME: Anxiety looks different even among the anxiety disorders, as a psychiatrist with panic disorder explained

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CHRIS AIKEN: That pearl about remembering the first panic attack is very useful. If panic disorder goes on too long it can build up to a cascade of unending anxiety that no longer resembles the classic, uncued attacks of the early illness. When asked if their anxiety attacked are spontaneous or triggered, they are likely to list dozens of triggers – stress, driving, leaving the home, conflict, loud noises… they associate the attacks with random events, and those panic attacks no longer seem spontaneous. But remember – the DSM requires that only one of the attacks was uncued – so you often have to dig back to that first attack to clarify the diagnoses. I think of a middle aged women whom I was convinced had lifelong generalized anxiety disorder until I asked her what she was like as a child. “I didn’t have any anxiety,” she said, “Until that first panic attack when I was 15.” When we got the diagnosis right, we got the treatment right.

KELLIE NEWSOME: Some symptoms are left out of the DSM altogether, as this clinician in recovery from alcohol use disorder explained….

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CHRIS AIKEN: A big thank you to everyone who shared their story.

KELLIE NEWSOME: We’ll be back with more insights from wounded healers. In the meantime, the May edition of Carlat Psychiatry News will be out in a few days. To find it, click on Webinars on the Carlat Report Website – it’s under the Multimedia tab. The Carlat Report is one of the few CME publications that depends entirely on subscribers. Thank you for helping us stay free of commercial support.

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.