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Today I would like to return to a theme that we have mentioned several times on these pages, taking my cue from a serious episode, the one that occurred on the evening of January 25 in Martinengo, a town in the province of Bergamo, where Mrs. Caryl Menghetti, who had previously been subjected to a TSO (mandatory medical treatment), killed her husband with 20 stab wounds. On the morning of the same day she had been examined by the hospital psychiatrist and had been discharged.

Let me make it clear right away that I do not want to judge the work of the psychiatrist who examined the patient; I know nothing about the case and it would be very unfair to make a keyboard judgment, as is unfortunately often the case these days. I am only interested in taking a cue from this episode to address a broader issue 

I quote some passages from the article that headlines like this, “How is it possible that the woman who killed her husband was not admitted to psychiatry after hallucinations?” “Explaining this to is psychiatrist Massimo Clerici, Director of the School of Specialization in Psychiatry at the University of Milan Bicocca and Director of the Department of Mental Health and Addictions of the ASST of Monza.”

“Is it then possible to discharge a patient who arrives with hallucinations and delusions?”

“There are patients who come to the emergency department with a generic request for help. One would need to understand whether at the time the patient arrived he or she claimed to be hallucinating or whether he or she was in such a severe delusional state as to warrant admission. In this case, it is clear that the psychiatrist will be evaluated for the choices he made. It may also be that this person presented to the emergency department by not declaring his or her mental state. Many psychiatric conditions, the most severe ones in particular, do not allow for an awareness of illness on the part of the patient. There are pathologies, such as schizophrenia, where severe symptoms are hidden because patients are not aware of them. I have been a psychiatrist for 40 years. I have seen so many patients who come in with a generic request for help hiding a serious situation, and it is very difficult with an interview to be able to tell if the patient has severe symptoms such as hallucinations or delusions: it takes a lot of patience, assessment skills but also a lot of luck. Many patients do not tell what they are experiencing. If they hide the severity of it from us, it’s not easy for us.” 

“Is it possible that the drugs did not take effect immediately?”

“We do not know how long ago the patient’s treatment had been changed and what kind of medication he was taking. However, we in the emergency department work with drugs with immediate effect that act within a few hours. In case of severe symptoms, we can intervene with an intramuscular drug or through an IV. After keeping the patient under observation, we may notice that psychomotor agitation or severe symptoms are greatly reduced and controlled. Therapies are rapid absorption with high-dose drugs. There are situations that may require hospitalization because the drug has to be administered several times, but others where the dosage succeeds in sedating the seizures.” 

So if the patient does not say what he has, the psychiatrist is unable to make a diagnosis? Are you kidding me? And so the identity of the psychiatrist is what? That of knowing the DSM5 (Diagnostic and Statistical Manual of Mental Disorders) by heart and knowing everything about neurobiology, but being incapable of making a rapport with the patient that would allow him or her to understand him or her as a human being, sick as you like but still human? Instead, when it goes well, a sedative and home!

Now excuse me, I am going to say things that are a bit boring, but we need them to understand.

As far back as 1941, the Dutch psychiatrist Rumke coined the term praecox gefuhl, feeling of schizophrenicity, by which he denoted that feeling of estrangement and bewilderment of the clinician when confronted with a schizophrenic, a failure to get in touch with him, thus coming to formulate, through these feelings, a diagnosis of schizophrenia, using his own sensitivity, training and presence in the relationship, without needing the patient to say what he was experiencing and regardless of whether or not he was hiding the seriousness of his situation. At the same time, in Psychoanalysis, Paula Heimann was introducing the concept of countertransference, very similar to praecox gefuhl, and Psychopathology has been telling us since Jasper’s time that seeing the patient is not a seeing of the senses but a seeing of understanding. So there was a great deal of research in psychiatry in which the patient was seen not as an object to be observed from the outside but as a human being with whom to make a relationship and from that relationship to derive that feeling/understanding that is fundamental to making diagnosis.

However, it happens that around the 1970s, since there were so many schools with different theoretical orientations that gave rise to disagreements on diagnostic methodology, in order to give medical dignity to psychiatry and allow psychiatrists to use a common diagnostic system, we arrive at the various DSMs, and by DSM3 the various etiopathogenetic theories (which try to give answers about the cause of the disease) are set aside and what was a refined psychopathology is flattened and reduced to its merely descriptive aspect, that is, what the clinician sees. In fact, the DSM3 is called atheoretical. So you end up with a series of symptoms, more or less equivalent, and the presence or absence of a symptom determines this or that diagnosis, something that reminds me of playing with figurines as a child: this one I have, this one I miss! The DSM5 has been called “the bible of psychiatry,” that is, the main not to say the only reference for psychiatrists in formulating diagnosis in clinical practice. Keep in mind that there are 541diagnostic codes in the DSM5!

It is obvious that this approach is not at all atheoretical because disregarding the patient’s experience and not looking for the cause that may have triggered the crisis but limiting oneself to this descriptive observation of symptoms is only possible if one has a biological/genetic approach, so the patient’s history does not interest me, I just need to identify the right drug to repair the “broken piece”! You can imagine with what advantages for the pharmaceutical companies. It is as if we are only interested in the wrapping and not in the content, which therefore remains absolutely incomprehensible.

And so we have arrived at today’s paradoxical situation whereby, while on the one hand we discharge the serious patient who goes home and commits murder, on the other hand we medicalize everything, just think of the exponential growth in recent times of children labeled with ADHD (attention-deficit/hyperactivity disorder) or intermittent explosive disorder or autism. And even when it comes to children, drugs are administered, without the slightest understanding that if that child is so pissed off some reason will be there and anger is perhaps the only thing left for him to express his rebellion to a violent context, including the psychiatrist. Likewise, one can no longer distinguish those who are healthily sad because their girlfriend left them and they need HIS time (and not what the DSM5 stipulates) to process the separation, from those suffering from depression, the answer is always the same: drugs. And we could go on and on with such examples.

There would be much more to say about the training, human and professional, of the psychiatrist and the schools of psychotherapy, but we will have time to talk about that again.

Marco Michelini


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Credits by: Sergi Montaner