I was taught CBT during my residency by an empathetic psychologist in an open-ended, formulation-driven manner. I was taught psychodynamic psychotherapy by a wise psychoanalyst-psychiatrist who emphasized the relational aspects & the field’s long intellectual tradition. /1
I feel I have seen the best of both worlds. I have no antipathy towards CBT or psychoanalysis because I have seen what both can do in capable hands. I have also seen how the spirit of these psychotherapies can wither under institutional demands & mindless bureaucracies. /2
P.S. Ironically, I was taught interpersonal psychotherapy by a researcher, very manual driven — quite a different experience. /3

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More from @awaisaftab

5 Mar
1/ Since "evidence-based medicine" is not uncommonly used as a weapon to dismiss clinical experience (including patient experiences) and is used to maintain a hyper-skeptical attitude that in the absence of well-designed RCTs no judgment can be formed, it is helpful to...
2/ ... revisit the words of David Sackett, one of the fathers of EBM, who offers a very different picture:

"The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research...."
3/ "Good doctors use both individual clinical expertise & the best available external evidence & neither alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for>>
Read 6 tweets
27 Feb
1/ A🧵on the new Harrow et al paper "Twenty-year effects of antipsychotics in schizophrenia and affective psychotic disorders"

I really like the paper, and I try to make sense of it while avoiding uncritical acceptance as well as uncharitable rejection.

2/ It's remarkable that we have 20 yr follow-up data! This is extremely valuable for anyone interested in longitudinal course. It is important to however realize that it is a naturalistic study; subjects were not randomized to receive or not receive antipsychotics.
3/ This was a decision made by subjects/families/doctors in the course of their care (or lack of care) for a variety of possible reasons. These reasons are not known to us. Harrow et al are following the individuals and tracking the treatment they have received & their outcomes.
Read 16 tweets
10 Feb
1/ I do think a lot of problems with current practices in psychiatry have to be do with system issues, however, these system issues have been synergistic with a variety of conceptual, scientific, & ethical problems that have to do with reductionism, diagnostic reification...
2/ ... eclecticism, manipulation of "evidence-based" medicine, neglect of phenomenology, lack of attention to power imbalances and systemic coercion, neglect of iatrogenic harm, & unreflective reliance on medicalization as the default for mental health care.
3/ An examination of these issues is not about blaming individual clinicians or researchers, or even about blaming psychiatry as a medical profession isolated from other disciplines, law, and society. These are larger forces that transcend any single individual or profession.
Read 6 tweets
7 Feb
1/ "it is overwhelmingly likely that the differences in symptomatology which the DSM taxonomy captures reflect the contribution of the neural, neurochemical, and genetic differences, *plus* differences in higher-level factors: broadly, social and cultural factors." Neil Levy
2/ "These include (but are not limited to) the ways in which different mental illnesses are conceptualized in a society, the ways in which social roles are assigned & understood,...
3/ "... and perhaps idiosyncratic facts about the individual and her history which result in her having beliefs that modulate the form that her illness takes."
Read 6 tweets
29 Jan
1/ "Whereas symptomatology is strictly illness oriented, psychopathology is also person oriented, since it attempts to describe the patient’s experience and her relationship to herself & to the world."

G. Stanghellini & Matthew Broome (@matthewrbroome)

2/ "The patient is an active partner in the diagnostic process, capable of interpreting her own complaints. Symptoms are conceptualised as the outcome of a mediation between a vulnerable self and the sick person trying to cope with and make sense of her complaints."
3/ "The existing classifications of mental illnesses are merely provisional diagnostic conventions... if psychopathology is conflated with nosography, only those symptoms that are supposed to have diagnostic value will be investigated,...
Read 5 tweets
5 Jan
1. Great paper by @HengartnerMP & @Altostrata, based on quantitative analysis of a case series. Given the paucity of previously published literature on this, this is an important contribution. Some thoughts and questions that come to my mind:

2. Chouinard & Chouinard criteria also specify criteria related to reversibility of symptoms & partial/total response to reintroduction of discontinued drug. It is unclear if these criteria were also applied as selection criteria.
3. To the best of our knowledge, unless future studies show otherwise, PWS appears to be a rare occurrence, but even rare occurrences can become common if the number of people being treated is large enough, & this is no reason to disqualify the suffering of those afflicted.
Read 8 tweets

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