in a book titled  doing psychiatry wrong  the author ( a psychiatrist ) describes several cases treated with medications , mostly inappropriately ( e.g. , patient with borderline personality treated as bipolar disorder , multi drug abuser treated as schizophrenia ) , without much gain .
another author ( a sociologist ) argues that in spite of the evidence that psychiatric conditions improve best with a combination of medicines and therapy , psychotherapy is rarely offered .
that author 's research has shown that such patients who were treated only with medicines 
do less well , are readmitted more quickly , diagnosed more inaccurately and medicated more randomly .
this case was inaccurately diagnosed , randomly medicated and did less well . properly conducted psychotherapy has improved the patient .
are we in to a second wave of anti - psychiatry movement against biological imperialism ?
a 23-year - old male , b.e student from upper middle socio - economic status , accompanied by his parents , presented with the complaints of anger outbursts , inability to mingle with people and inability to study .
for the past 2 years , he attended neither the classes nor the home tuitions .
most of the activities , which he tried to do ended in failure and angry frustrations .
most of the time was spent in sleep , which was aided by sedative psychotropic medicines .
he could not tolerate inactivity as it led to boredom and this was intolerable . remaining small time in the day he displayed a
 typical pattern  of behavior as noted by pedesky and beck  they may discontinue a task or fail to initiate a task they had planned to do .
they may turn on the television , pick up some things to read , reach for food or a cigarette , get up and walk around and henceforth .
mental status of the patient was that of an inhibited plump person with expressionless serious face , answering questions minimally , but relevantly without any psychotic symptoms .
most of his anger outbursts erupted and lasted only for a few seconds and a few are followed by grumbling and shouting for about 10 min .
anger resulted in yelling with angry gestures , banging , crumpling , throwing , tearing and breaking of objects ( one per attack ) such as shirt , pen , pencils , spectacles , remote control and rarely , mobile phones or computers .
he avoided close relatives , strangers and crowds as it induced severe fear and inhibition .
he was scared to talk to house maid , lift operator in the apartment , traffic police and ladies .
he looked away from them and walked away at the prospect of an approaching lady .
in fact his first visit to a psychiatrist was due to fear of lead contamination from wall paints .
his other fears were , being cursed by god , old and sick people if they are disturbed by mistake , fear of going deaf or blind by strong sounds or bright light .
he had magical beliefs that bad words if heard in the early morning , they will spoil the whole day and if any bad word is heard while praying , god will curse .
he had rigid moral values in the matters of sexuality , religion and right or wrongs .
he got infuriated with matters such as muslim religion , female gender , britons , beef eaters and rule breakers .
he was pre - occupied with his sagging chest and wore tight banyans to hide it .
he wanted to understand the subject perfectly and this inability led to a sense of failure and frustration and anger .
patient was born to a highly educated and well - employed couple hailing from upper socio - economic status .
his first degree paternal uncle has a chronic psychotic illness , but he is too highly educated and regularly employed .
however , he was noted to be angry and used to kick walls if he got angry . in 10 and 11
standard he was bullied frequently by few students and ridiculed for his sagging chest by touching it .
patient remained un - assertive and the abuse and emotional trauma inflicted was significant . during adolescence
his past psychological assessments revealed above average intelligence and presence of several personalities disorder traits and low self - esteem . he was treated by more than a dozen of psychiatrist , exhausting all psychotropic medicines , including clozapine at 200 mg / day .
when he visited the author he was on lithium 400 mg , fluoxetine 60 mg , amisulpride 100 mg , quetiapine 50 mg , clonazepam 3 mg , pregabalin 300 mg .
cognitive therapy espoused by pedesky and beck was administered over 1 years , weekly 1 - 2 sessions of 1 - 2 h duration .
schema modifications , behavioral experiments , cognitive restructuring , brief repeated exposures ( real and imaginary ) , exposure and/or response prevention for obsessional symptoms were used during therapy .
psychiatrist trained to diagnose patients using atheoretical diagnostic systems and to treat by medicines is likely to over diagnose a psychotic illness in this case and treat accordingly . a flat affect ,
minimal talk , inhibited appearance , apparently unexplained anger outbursts and psychotic illness in a family member can lead to a misdiagnosis .
a closer look reveals his warm affect , a keen interest to socialize and reasons for his anger .
in fact historically this patient might have diagnosed as pseudo - neurotic schizophrenia , because of pervasive fears , phobias and strange sexual fantasies . in the past , severe avoidant cases were clubbed with schizoid personality .
knowledge of cognitive theory and therapy helped the author to arrive at a right understanding ( diagnosis ) of the patient and consequently the proper treatment .
patient warrants an additional diagnosis of intermittent explosive disorder because aggression is not a part of avoidant personality .
he also had anankastic personality disorder , obsessive - compulsive disorder , body dysmorphic disorder and paraphilia and even a dhat syndrome .
one of the foundations of cognitive theory and therapy is that the appraisal ( personal meaning given ) of the events results in the emotions .
similarly , his social fear can be explained by extreme sense of shame , sensitivity to insult and appraisal of people as dangerous and  paranoid  ( patient 's own word ) about him .
the  typical pattern  of behavior noted earlier , can be explained by the cognitive and emotional avoidances .
patient was intolerant of dysphoria and to reduce it , he repeatedly attempted to do one or the other activity .
this case proves that psychotherapy can be a mainstay of treatment even in severe personality disorders .
 over dependence on pharmacotherapy in psychiatry , known as biological imperialism , is a world - wide phenomenon . 
 some authors have opined that the inadequate and ineffective utilization of psychotherapeutic interventions and only dependence on pharmacotherapy amounts to institutional malpractice . here is an example of such a case . 
 a young male mainly received multiple psychotropic medicines , including clozapine ( and also a failed psychotherapy ) over a period of 4 years , without any benefit . 
 his global assessment of function score remained at 30 . 
 however , with proper diagnosis and effectively conducted psychotherapy a significant improvement in global assessment of functioning score of 70 was achieved , over a period of 1 years . 