Misdiagnosis: How Psychiatry and Over-Medication Failed My Sister

Introduction

I would like to preface this essay with an acknowledgement of the body of work in psychiatry that has helped millions of people over its long history. This is not an attack on psychiatry itself, it is regarding the specific history of my sister’s struggle with mental illness and substance use. This document is not to be applied to psychiatry in general, but only to this particular instance.

Psychiatry failed my sister through misdiagnosis, over-prescribing medication without biological evidence, and lack of any meaningful follow-up to assessment and diagnosis. I am also aware that this is not the practice of all psychiatrists. I am certain that there are many great psychiatrists out there that incorporate much of what I will be discussing as solutions. This is only the case study of my sister.

I will also acknowledge that this is not the fault of my sister's psychiatrist alone. Some of the blame must be laid at the feet of all the family members, especially my sister. She made decisions that exacerbated her illness as well as made choices that prevented her from taking other forms of help that she needed, such as psychologist appointments that I tried to arrange for her. Having to wait 6 months or more to get an appointment with a therapist or any kind of treatment centre made it very difficult for her to have faith in the mental health system. While she is to blame for some of her choices, she is not at fault for the scattered, chaotic life she had to lead.

To better understand my sister’s struggle with mental illness, as well as my own, and to get the history of abuse we suffered, I recommend reading my previous articles about the subject here:

Finding Balance: Using Cannabis to Mitigate Grief and Trauma | LinkedIn

Here:

Vitriol: Narcissistic Parental Abuse | LinkedIn

And here:

The Authentic Self | LinkedIn

We should begin by discussing the difference between psychiatry and psychology. Many people use these terms interchangeably; however, there are distinct differences between the two. As someone who has studied psychology at university, has struggled with my own psychological issues, has done exhaustive studies over the last number of years to understand what my sister and I went through our whole lives, as well as been assessed and diagnosed by both a psychiatrist and psychologist, I can provide you with a patient and student perspective and interpretation of the difference. I have come to understand that psychiatry is the biological study of mental illness such as biochemistry, neurotransmitter systems, sympathetic and parasympathetic systems, etc. Psychology is about studying the social aspect of mental illness such as family dynamics, trauma and event history, and implicit and explicit memory analysis. Psychiatry is trying to understand the biological reasons for mental illness, psychology is an attempt to understand the sociological causes of mental illness.

The Circumstances

My sister had her first experience in a hospital ward for her eating disorder at the age of 15. She spent over a month locked down in a ward with other girls suffering from bulimia, anorexia, substance use, self-harm, and suicide ideation. My sister suffered from bulimia and self-harm at this time. She was monitored 24 hours a day, had to have permission and observation when using the bathroom, and had a feeding tube stuffed down her throat to put on weight. It was during this internment that she was introduced to a psychiatrist and began regular medications to assist her. Of course, I am not privy to her medical history to know the exact prescriptions she was given, but I was told that they were antidepressants and anti-anxiolytic medications. What was not properly investigated at the time was why. Why was she suffering from this eating disorder and self-harm? The reason I was told: her dance instructors were putting on constant pressure to be thin and beautiful which developed into body dysmorphia.

Curiously, she was the only one in her classes, that I am aware of, who suffered to this extent from the harmful teachings of her instructors. At this time, her parents were the main contacts and sources of information for my sister’s doctors which resulted in a diagnosis by proxy. If you have read the previous articles about our family history, you may now understand that their interpretation and representation of the truth would be skewed with self-serving inaccuracies and outright lies. It is now understood that my sister was suffering serious emotional abuse at home from my mother and stepfather. Further, the programming from our parents to lie about what happened behind closed doors would have precluded my sister from being honest about what she endured due to expectations of punishment, denial, and rage from my parents if she spoke about it.

Thus came a diagnosis of her first mental illness, determined to be Bipolar Disorder (BD) at the young age of 15, and her first handfuls of medications to try to correct some kind of chemical imbalance in her brain. She completed her treatment, was given some prescriptions, and sent on her merry way with little to no follow-up or therapist sessions, and everything changed for the rest of her short life.

Around the same time I was suffering from mental health and substance use issues as well. Gaslighting was regular practice in my family and my parents had told me that there must be something wrong with me and I needed to see a psychiatrist. So, I did. I sat down with a psychiatrist - for one session - and he diagnosed me with Dysthymia, now called Persistent Depressive Disorder (PDD), on the spot. He prescribed me some antidepressants and sent me on my way. There was no follow-up, no recommendation to a psychologist, and no real explanation about why I was suffering from PDD. Now, I was under the belief that there was something wrong with my brain and began to question who I was and my sanity. This led to the beginnings of my Substance Use Disorder (SUD) and my first steps into self-destruction. The prescription did not last long, and alcohol and street drugs became the substitute.

Being given a diagnosis like this and being told that there is something wrong with your brain or you as an individual, erodes the self – self-esteem, self-worth, and self-confidence, and creates enormous self-doubt; especially in the mind of a young teen that is already questioning their place in the world. You begin to question who you are, doubt your experiences, and makes you fear the future. Without a complete understanding of why my sister and I were the way we were, the focus became inward instead of trying to determine if there are any external influences that may have caused our suffering. It would not be until my late 30s when I started to see a psychologist and do a deep dive into my family history that I came to understand that there was nothing wrong with me biologically. My mental illness was directly related to my family history and dynamics and an extensive history of Narcissistic Parental Abuse (NPA). Not just me, but my sister as well, and after I escaped on my own, she took the full brunt of that abuse.

My sister would end up in inpatient treatment no less than 9 times over the course of the next 20 years (I don’t have exact numbers but that is the number I know); sometimes in hospitals, others in rehabilitation centres. She would sometimes meet face-to-face with her psychiatrist, but mostly it was over the phone or by video. The focus remained on some kind of chemical imbalance in her brain and the medications kept changing or increasing. However, in her early twenties, my sister discovered cocaine and began drinking heavily. The cocaine allowed her to not eat, and she continued to suffer from bulimia and self-harm. She had stopped dancing many years previous so, why? Why would these issues continue if she was no longer suffering from the indoctrination of her dance teachers about body image? Unfortunately, her drug use spiraled and the company she kept to attain those drugs led to her being a victim of severe violence and rape in her mid-twenties.

Now she was struggling with Post Traumatic Stress Disorder (PTSD), but her psychiatrist was continuing to maintain her BD diagnosis and prescribe her meds based on that diagnosis. According to some journals I have had access to since her death, I believe she was beginning to understand that this was about the abuse she was having to endure at home. However, without meaningful follow-up after regular rotations in rehab, as well as continually being forced back into my parent’s abusive home or being abandoned on her own in another city by my parents to ‘toughen her up’, not only did her illnesses continue, they got worse. Over the next number of years, our family would experience suicide attempts, lies and manipulation, tantrums and screaming, substance use, and violent behaviour from my sister.

At this point, for my sister in her mid-twenties, the repeated cycle of rejection into rehab, abandonment from the family to her own place or a different city, lack of support from her parents to continue therapy, and dependence on medications and alcohol and street drugs, leading to relapse and rehab, would go on for another 10 years. She would meet with her psychiatrist irregularly over the phone or via video chat. Her diagnosis was altered from BD to Borderline Personality Disorder (BPD). The medications changed or increased to more than 20 pills a day and now included antipsychotics and benzodiazepines. She would be tossed around from therapist to therapist telling and reliving the same horrible experiences to the point that she gave up trying because she could not relive the traumatic events anymore. She started to turn to the bible for help. She abandoned her son at Christmas for a bender that would result in her death in a hotel room bed, alone.

The Failure

So, how did psychiatry fail my sister? While there are numerous articles out there about the failures of psychiatry, I would like to use this list as a succinct guide: 10 Biggest Problems with Psychiatry - Mental Health Daily My sister was a victim of no less than 5 of these points. The main ones are:

1.??????Inaccurate Diagnosis

The initial diagnosis of Bipolar Disorder for my sister was pre-emptive and irresponsible, as well as negatively impactful on her self-esteem and self-worth for the rest of her life. First, her brain at this point was not fully developed and should proper psychological and behavioural treatment have been given, there may have been a very different outcome. Second, this was a guess at best. The psychiatrist was likely unaware of the abuse my sister was suffering at the hands of my parents, nor the situation at home. My sister was likely suffering from Complex Post Traumatic Stress Disorder (CPTSD) as the symptoms of CPTSD and her re-diagnosis of BPD are very similar but are the result of very different experiences and require different types of treatment. My PDD diagnosis was likely due to similar circumstances as I have now been diagnosed with CPTSD. This label of psychopathy influences and guides our decisions for the rest of our lives.

2.??????“Chemical imbalance” Theories

How do you justify a diagnosis of chemical imbalance in a 15-year-old whose brain has not even fully developed? How do you justify stating that someone has a chemical imbalance, or misfiring neurotransmitters, without a battery of tests of the various systems that would be involved, especially the brain? Perhaps prescribing a Selective Serotonin Reuptake Inhibitor (SSRI) to a 15-year-old damaged her ability to properly balance the serotonin in her brain for the rest of her life. Perhaps she did not have a chemical imbalance at all but was suffering from severe trauma and abuse in her life and she did not need drugs but a safer environment and therapy. Without tests and exams and imaging of a myriad of bodily systems related to chemical maintenance in the brain, claiming ‘chemical imbalance’ is just a theory, not a fact. This also relates to number 4 of the list ‘Poor understanding of pharmaceutical drugs’ as well as number 5 ‘Failure to look at the brain’. Without the knowledge and science to back up this theory, prescribing a medication based on minimal information is guesswork at best. It is guesswork that can actually make things worse without evidence to support it.

3.??????Prescribing Temporary 'Patches' (3) and Overprescription of Dangerous Drugs (6)

This not only relates to prescribed legal drugs, but to the illicit drugs many are using since SUD is often the result of trauma and mental illness. Both these legal and illegal substances are manipulating the same transmitters in the brain. Typically, these are serotonin, dopamine, GABA, and endorphins. One of the times I was prescribed Citalopram, an SSRI, and Zopiclone, a hypnotic for sleep, the Citalopram was rendered ineffective due to my alcohol use and caused some suicidal thoughts; however, I discovered that taking a number of Zopiclone mixed with alcohol, if you power through the initial drowsiness, creates an almost psychedelic experience and I started to misuse them. Mostly, this is about the continuation of new or increased doses of prescription medications my sister’s psychiatrist continued to dump on her without any medical evidence that this is what she needed. These medications are supposed to be temporary yet my sister was on the same medications for almost 20 years. This should have been a clear indication that she was not responding to the medications and the focus should have turned to try other methods that may have been more effective.

4.??????Lack of Empathy (7)

This one is clear. The ‘in and out’ metaphor is apt. The procedure of minimal engagement or testing before diagnosis, guessing at a medication to prescribe, lack of meaningful follow-up, as well as a lack of understanding of the environment or history of a patient, makes the immediate prescribing of medication and passing over to other services especially cold. It is clinical and detached from what a patient is truly going through. Without fully understanding the sociological aspects of the patient there can be no empathetic understanding of the background and history of the patient. With my psychologist I felt nurtured, heard, and understood. Because she knew what I went through, I felt safe and that I was being treated with compassion. My sister described her talks with her psychiatrist as cold and detached, with them barely listening and then stating that they would increase or change the medications with little to no explanation.

5.??????Outdated Practices & Misinformation (10)

I will focus here more on the ‘misinformation’ part than ‘outdated practices’ as the latter would be assumptions on my part about the level of education the psychiatrist had and whether their training was current. Regarding misinformation, again if you have read my previous articles about my family dynamic, you would realize that any information my parents would provide would have been skewed in their favour, or blame shifted to others such as her dance instructors. This would result in inaccurate information being provided to my sister’s psychiatrist, especially when she was under the age of consent. Even my sister, after years of being denied her authentic self and programmed to never speak about the abuse she was suffering from her parents, would have been terrified to share that kind of information for fear of the repercussions. She would have been called a liar and demeaned and suppressed; her truth denied by our parents to protect themselves. Whom would a psychiatrist believe at the age of 15? Even as she got older, that programming would get stronger and she would continue to deny the abuse since she was perpetually gaslit to believe that there was something wrong with her, not our parents.

The rest of the items on that article’s list are more about issues with the psychiatrist than the relationship between the doctor and the patient so I will not make assumptions there. As you can see there are consequent failures in diagnosis from the beginning. Once the diagnosis was made, the assumption continued up to her death. Even in her 30s while she was having night terrors and wetting her bed the BPD diagnosis remained. While many of the depression and anxiety symptoms, as well as her attachment and abandonment issues fall into the BPD diagnosis, including these newer symptoms should have resulted in a diagnosis of PTSD from her rape. On top of that, her lifelong battle with the NPA folded her into the CPTSD category as well. Further, the lack of support from my parents for her to get better, the denial of the abuse in the family, and the suspicion of falsifying the rape by our parents, created a complete feeling of abandonment and denial of her reality.

How to Improve

So how do we improve or prevent a situation such as this? Early and preventive education, integration of different mental health services, better communication and understanding, and proper testing of biological systems prior to the offering of prescription medication. As soon as it was determined that my sister was suffering from her eating and self-harm disorders, more emphasis should have been placed on interviewing the whole family to better understand the family dynamics. Certainly, a 15-year-old should not have been locked away in a medical ward which would have been extremely terrifying and traumatic for such a young individual.

Even during my own session with a psychiatrist, I was too afraid to speak about what was going on at home. Keep in mind that without any kind of reference to normal, healthy parent-child interaction, children are typically unaware that what they are going through is abuse. My sister should have been referred to a child psychologist first to give her a safe space to feel understood and be free to discuss what was truly going on. A child psychologist may have been better equipped to nudge the truth out of her about what was happening. Instead, the assumption that there was something wrong with her brain led to medications that potentially and fundamentally changed the way her brain was developing.

Further, with the type of abuse she was suffering, this diagnosis would have decreased her sense of self which was already denied her by our parents. She now was treated differently by family and friends and made to feel more unaccepted than she already felt from the rejection and gaslighting. Regardless of whether she truly had BPD or PTSD, these are behavioural ‘disorders’ that could have been changed through Rational Emotive Behaviour Therapy (REBT) techniques such as Cognitive or Dialectic Behaviour Therapy (CBT and DBT) which should have been tried first. If the psychologist determined that this type of therapy was not sufficient then she should have been referred to medical biological testing to see if there was something wrong with her brain and neurotransmitter systems. ONLY THEN should she have needed to see the psychiatrist and medication be prescribed once a biological factor had been identified. Medication should be the last step in a long series of steps to an evidence-based biological diagnosis. There is also the option that the psychologist should have the ability to prescribe minor drugs that may assist in behavioural change. However, this should only occur once it is determined to be applicable to that behavioural change, such as an anti-anxiolytic, not on the assumption that there is some sort of chemical imbalance in the brain.

Lastly, is consistency. Someone suffering with so much trauma and abuse has a significant amount to work through, which will take years. I am fortunate, I have been working with the same psychologist for 12 years now. I don't see her every week, or even every month, anymore as I only need her when I'm struggling and can make an appointment if and when I need it. My sister did not have this. As mentioned, she was tossed around from therapist to therapist. She would be put on waitlists for months at a time only to have one or two sessions, then be recommended to someone else. Eventually she was too old to be covered under my parents' medical coverage and she could not afford the appointments anymore. She was then relegated to government listed therapists who would switch around and be prone to turn over. Thus my sister would have to tell her story repeatedly without any progress. She became jilted and distrustful of the mental health industry and kept trying on her own. She needed consistent and comprehensive therapy with someone who knew her story, knew her past, and knew her progress.

Complications With Substance Use Disorder

As someone who has dealt with and defeated SUD, I know how easy it is to lie to a healthcare practitioner about your drug use. The guilt and shame of using make it very difficult to be honest about how much or how often you are taking various substances. On top of that, the gaslighting, manipulation, and control of narcissistic parents make you question your reality, so you struggle with being honest about what you have gone through and are practiced in lying about who you are and your negative behaviours. Interactions between alcohol, cocaine or other street drugs, and prescribed medications create massive chemical imbalances in the brain and render some medications ineffective or potentially contraindicated. My sister would sometimes become an absolute freight train of mismanaged emotions and behaviours that could turn violent if she was mixing her medications and alcohol and illicit drugs.

When prescriptions that alter the chemistry of the brain are recommended there needs to be a consideration for illicit substance use interactions. There appeared to be an assumption on both my psychiatrist, and my sister’s, that saying ‘do not take these with alcohol or other drugs’ would result in a cessation of illicit drug or alcohol use. This is ambitious thinking and highly unlikely. When someone is in the throws of SUD, suggesting that someone stop all the drinking or illicit drug use they had been medicating themselves with can be terrifying; especially if SUD has been part of their lives for years. The expectation that somehow someone suffering from SUD will magically quit their addiction for medications that might take weeks to have an effect is delusional. For any consideration of prescription medications, there needs to be the involvement of a recovery program for illicit drug or alcohol use first. Only once the individual is free of their addiction will any medications that manipulate the same neurotransmitters be effective, in any way.

There is a term in the recovery field that also applies here, called ‘substitution’. This is where one substitutes one substance for another to get the same effect, causing one to believe that they have defeated their addiction only to discover they have just substituted one addiction for another. Some of the legal prescription medications are just as addictive as any illicit substance one may become addicted to. However, the more typical behaviour that develops is dependency. When someone is using a substance, any substance, to manage emotions or behaviours, the brain and body may become dependent on that substance to continue to manage and balance those emotions and behaviours. Without involving behavioural changing techniques through CBT and DBT there can be no real change in the need for these substances. This is also true of opioids and is at the root of the current epidemic. The opioids provide the endorphins that not only help manage physical pain but mental traumatic pain. Once a patient discovers that the medication stops the pain of their injury as well as their mental anguish, the hooks are in, and once they can no longer get it legally, they turn to illicit drugs to get the same feeling. Any sociological issues that are causing the need for substances must be managed before one can be truly free of addiction.

Other Options

I have written extensively on using cannabis for harm reduction and recovery. Instead of treading on the same ground, those articles can be found here:

Opinion: How To Improve Canada's Addiction Recovery Support System | LinkedIn

And here:

Cannabis and Recovery | LinkedIn

I genuinely believe that I could have helped my sister immensely if I was able to implement a microdosing cannabis plan for her to follow. Unfortunately, the cost of cannabis, as well as restrictive government social work programs she was involved in that required strict sobriety standards precluded her from having this option. Cannabis may help, in many ways, manage symptoms of mental illnesses and balance emotions. There are numerous studies that have come out recently showing the efficacy of cannabis in aiding these symptoms without severe changes in brain chemistry and only mild dependency side-effects that are easily managed. This is the practice of harm reduction for her recovery that could have led to the path of prescribed medications to assist in rewiring her brain if it was deemed necessary. I believe implementing a program such as SMART Recovery, which uses a CBT base and has specific dialogue for self-harm and eating disorders, along with a balanced cannabis program, would have helped her manage the anxiety and depression, just as it worked for me.

For her CPTSD and PTSD, there have been great strides in the field of psychedelics which could have aided her to work through her trauma. Microdosing psilocybin has been exceedingly helpful to me in regulating my anxiety and depression after such a tragic year of loss. Unfortunately, the studies and research into this field were only becoming mainstream near the end of her struggles and were readily dismissed by our parents as nonsense, including cannabis. They perpetually denied the evidence of my recovery and treatment and continued to gaslight and deny that there was truly anything wrong with me, particularly my mother who believes that I have suffered no trauma and abuse and still maintains that thinking to this day. Further, a recent conversation with my mother continued this belief by blaming my sister for her own death and trying to insist that she killed herself.

Conclusion

I repeat that this is not an attack on psychiatry itself. I do believe that psychiatry is an essential mental health field of study and when there are legitimate medical and biological needs for altering brain chemistry that is in an imbalanced state, this is the route that should be taken. However, when it comes to behavioural disorders, a psychological route should be taken prior to a recommendation for psychiatric assistance. Once behavioural therapies are shown to be ineffective and rigorous testing and imaging of the brain and relevant systems show a misaligned or inefficient neurotransmitter system should a referral to a psychiatrist happen. Further, a holistic approach to mental illness should precede a biological change that includes the sociological background of the patient to better understand what is happening to the individual and get a complete picture of the causes of a particular mental illness.

What must also occur is an honest and truthful, and evidence-based, understanding of any substance use issues that the individual is suffering from. Mixing legal and illicit psychotropic drugs is very dangerous, with potential contraindications or elevation and suppression of the very neurotransmitters legal drugs are trying to manipulate. The assumption that someone suffering from SUD is going to quit using the substances they have been medicating with for years just because the drugs they have been prescribed ‘might’ work is self-deception and potentially destructive. Further, prescribing medications to a child whose brain has not fully developed creates massive concerns for me regarding how a child’s brain will continue to develop with the manipulation of neurotransmitters with no medical or biological evidence to support it. It may have been that my sister’s continued ‘chemical imbalance’, if she had one to begin with, was exacerbated, or even created, by the prescription of mind-altering substances at such a young age. For example, Health Canada claims that cannabis is harmful to youth due to potential changes to the brain during development; however, these legal pharmaceuticals, which absolutely do very dramatic changes to the neurochemistry of the brain, can be given without any medical evidence that they are needed?

My sister’s diagnosis should have followed these steps:

1.??????Establish behavioural patterns and mental illness symptoms to have an accurate diagnosis;

2.??????Referral to a child psychologist to determine external sources of abuse or trauma, family history and sociological and environmental concerns, as well as any substance use issues;

3.??????Implementation of Rational Emotive Behaviour Therapy (REBT) based therapies such as Cognitive or Dialectic Behavioural therapies;

4.??????Consideration of alternative therapies such as cannabis or psychedelic therapies;

5.??????If the mental illnesses continue, referral to a doctor for biological and medical testing to determine if biological systems are out of balance;

6.??????Referral to a psychiatrist for prescription-based treatment that includes REBT practices and collaboration with a psychologist to establish healthy behaviour patterns;

7.??????Continue to observe behaviour with regular therapy and maintain medications being especially cognizant of any substance use addictive or dependent behaviours.

Instead, my sister’s diagnosis was:

1.??????Engage only the psychiatrist without any prior or other mental health professional engagement;

2.??????Psychiatrist interviews the subject and assumes chemical imbalance while the brain is still developing, basing diagnosis on insufficient evidence;

3.??????Prescribe medications based on misdiagnosis or inaccurate diagnosis from a lack of substantial evidence, change the brain forever;

4.??????Use apathy and lack of empathy to disconnect from the patient, ignore substance use issues, and increase or change medications based on assumptions and speculation;

5.??????Watch the patient spiral toward madness and complete loss of emotional control and continue to insist a misdiagnosis is correct.

6.??????Patient suffers horribly and struggles further due to unmanaged external factors of their mental illness.

This may seem harsh, but it is accurate. The key factor about how mental illness is viewed by the psychiatry field is based on the belief that there is something biologically wrong with the patient and needs medication to correct it. This may be true in some cases; however, many, if not most, mental illnesses are caused by external sociological factors such as trauma and abuse. The initial assumption that there is something chemically wrong with an individual without having a full picture of the circumstances, or even medical evidence, is an egotistical misrepresentation of how mental illness occurs. A holistic, full picture of an individual must be established prior to attempting to change the chemistry of the brain. This is what failed my sister. This is how psychiatry failed to accurately diagnose and treat my sister’s illness. And now, it can never be fixed.