Wednesday, April 25, 2007

Face to Face

Reminder: Grand Rounds at Shrink Rap, BYOB, Submissions due by Saturday.

Sometimes, The Last Psychiatrist says things that make me want to scream. He did that the other day, in a post about the Virginia Tech shooter, he made the statement, and I quote:

"... Cho wasn't mentally ill. He was a sad, bad man who killed people because his life wasn't validated. There was no psychosis, there was no cognitive impairment, there was no psychiatric impairment in insight in judgment. There was a lack of sex, but that's not yet in the DSM. Not to reduce his life down to a soundbite, but he was a guy who thought he deserved better by virtue of his intelligence and suffering; found himself in a sea of mediocrity but couldn't understand why he couldn't therefore excel; and, worst of all, found that all the things he thought he deserved eluded him-- especially hot chicks, who not only dismissed him and found him creepy, but, worse, chose to be with the very men he thought were obviously inferior to him. "

Can I scream??? I don't want to defend this man, I haven't followed the news all that closely, and I watched one 3-minute video the killer made, though I will admit that statements he made along with some of his behaviors (for example, killing himself, or perhaps even the illogical thought process that might lead one to think that murdering innocent people makes one a martyr for one's nonexistant children) led me to think he might have a mental illness. On our podcast we talked about this in response to a reader's question and we didn't think a diagnosis of schizoid personality disorder was necessarily accurate or not, and we didn't think it was relevant to the act of mass murder.

I don't know how The Last Psychiatrist practices psychiatry. For me, when I do an evaluation of a new patient in my ideal bubble world private practice, I schedule 2 hours, I sometimes run a little over. I ask the patient about every aspect of their lives, including extended family history, descriptions of their parents' and siblings' personalities, detailed medical, occupational, romantic, legal, military, and habit histories. I ask about past episodes and treatment. I do a mental status exam. I request records, if someone accompanies the patient, I bring them in at the end of the interview to clarify history, get another perspective, talk about a plan. In less-than-ideal clinic world, I take a history and I often have extensive records from prior treatments.

I've never made a diagnosis based on a three-minute tape, one where I didn't get to ask questions.

How does The Last Psychiatrist know there was no impairment in insight or judgement (Give me a break, he thinks this guy had intact insight and judgement?) How does he know Cho didn't have sex? How does he know Cho was motivated by his anger about not getting the hot chicks?
Did I miss something here? The Last Psychiatrist seems to know an awful lot about the inner thought processes of a stranger.

Thanks for letting me scream. I'm done now.