Thursday, April 05, 2007

Taxing Taxonomy

During our last podcast we answered a question about whether or not pedophilia was a disease. Another earlier question we addressed was whether or not schizotypal personality disorder was related to schizophrenia. Our readers/listeners aren't the only ones questioning how to approach psychiatric diagnoses.

Today's American Journal of Psychiatry has a dense article on the "Conceptual Taxonomy of Psychiatric Disorders". It's an overview of philosophical approaches to the classification of mental disorders written by the folks working on DSM-V. The abstract alone is worthy of a philosophy major. I made it through the entire article but I promise never to bring it up on the podcast. The article considers whether or not psychiatric disorders are more like chemical elements (they exist naturally outside of ourselves, have common properties, and must be defined by exploration and discovery---known as essentialism) or whether at the other extreme they are created arbitrarily by mutual agreement separate from any underlying truths---known as nominalism.

And that's only one of the six "dimensions of categorization" they propose applying to current medical models. Thank goodness Dinah and I only had to consider the four perspectives. (Although I have to admit I enjoyed the part where they compared making a diagnosis across a continuum to slicing a meatloaf!)

Another diagnosis-related issue was addressed in a recent New York Times article discussing a study of depressive symptoms among the bereaved. In an article published in the Archives of General Psychiatry researchers compared bereaved depressed subjects with depressed patients suffering from other losses with regard to number and duration of symptoms, functional impairment and other measures. They found no difference between the two groups and concluded that many life losses could be used as an exclusion criteria for major depression. (My translation: "Of course you're depressed, look what you've been through.")

I think this article will serve to muddy the waters rather than clarify them. I deal with this issue frequently among my patients after a new diagnosis of major depression: "Of course I'm depressed, look where I am!" In fact the majority of prisoners are not clinically depressed. Most of the death row inmates I've seen have not been clinically depressed. All this study does is support the idea that psychosocial stress can precipitate disease---we already knew that. It supports the idea that current diagnostic criteria can define a syndrome separate from causation, which is a good thing. The one thing it doesn't address---at all---is how the disorder should be treated. And that's the main thing the New York Times article talked about.


Maybe I Am A Therapist

Just a couple of vignettes from today that I enjoyed:

Patient: "How do you know that bipolar disorder is a disease?"

Me: I go on about genetics and chromosomes and changes in neurotransmitters and response to medication. Then I do what I should have done to begin with: I ask the patient what he thinks is the cause of his multiple hospitalizations and suicide attempts.

Patient: "I think it's a government conspiracy."


(During intake assessment patient reveals he just had a bad phone call home. Brief crisis intervention provided.)

Patient: "Hey doc, can I come back down again and talk to you sometime?"

Me: "We have psychologists here if you'd like some counselling. I can set you up with one. I just work with medications; I don't really do counselling myself."

Patient: "Why not? You're a good one!"


Midwife with a Knife said...

Six dimensions seems like a lot. Yet another reason why I'm an obstetrician. All of our decisions (and most of our diagnoses) are dichotomous: deliver now, deliver later. Pregnant or not pregnant. Baby good or baby bad. Sick or not sick. Deliver vaginally or deliver by c-section. I'm not really smart enough for a decision tree with more than two branches! ;) What if they invented a whole new diagnostic paradigm, would everybody go along with it?

Then I was wondering about the nyt article; and I listened to a little piece on npr about it. I'm trying to figure out if they're saying that fewer people should be treated because people who are bereaved are being incorrectly diagnosed and/or not distinguished from the "real" depressed; or are they saying that rather than base treatment decisions on whether or not someone's had a recent loss, treatment decisions should be based on the severity of symptoms (i.e. someone with moderate to severe symptoms) should be treated whether or not they are recently bereaved, because bereavement behaves like depression.

I suppose I should go onto Pubmed and try to read the paper.

(and, by the way, you are a good one!)

Gerbil said...

Oh my god, you have unleashed SUPER DORK GERBIL. The question of diagnostic category vs. continuum has almost aphrodisiac qualities for me.

Soooo... who wants to read my dissertation on mathematically-derived classifications of deliberate self-harm? ;)

Anonymous said...

What a great synthesis, you are one amazing ClinkShink!

With regard to MWWAK's question: my read on the article was that Major Depression is overdiagnosed and overtreated in people who are "merely" having normal reactions (e.g. Sadness) to tough circumstances.

It's often a touch question and for myself, I've come to this conclusion-- Sadness and assorted symptoms are a normal response to loss. The normal response to loss, however, is to grieve, to lean on friends, to know that such suffering is a normal response. the normal response to loss is not to go to a psychiatrist. By the time someone wanders in to see me, it's because everyone else is saying their grief has gone on too long, the suffering is not letting up, they should be doing better. Psychotherapy can be very comforting and very powerful (and diagnostically, we can call this Adjustment Disorder, with depressed mood, if you'd like). But if someone comes in after a loss, meeting criteria for depression, and asking for medication (and yes, they ask, and no, I don't knock on their doors), that too can be very helpful. Though admittedly, I've had people get a lot better with very very low doses of meds, a handful of sessions, and that all powerful healer: Time.

ClinkShrink said...

MWAK: I'm with you. Just getting through the six continuum section was a labor (pardon the pun) much less the section where they interpret each medical modical using them. It's no wonder it took two years for this article to get published. The NYT article implied that people were being misdiagnosed and/or improperly treated but that wasn't the point of the Arch Gen Psych article really.

Gerbil: So many brains in such a little furry rodent! How many classifications are there? I bet I've seen them all. Especially the category where they swallow their cell piece by piece.

Dinah: Thanks that's sweet. One of the factors they compared was 'service use' which I take to mean intensity of treatment or type of treatment, something like that. So yeah, it's a self-defining group that probably does select out for more severe reactions/symptoms.

Anonymous said...

There is a difference between sadness and depression. One can still do daily chores, even if crying while driving to the grocery store. Depression keeps that same person from making a grocery list. Do meds help the person going through grief? I am sure of it. Bereavement is not handled the same as it was in our parent's generation. We live in a World where many people now believe that there is no time for grief. "Get on with your life". Our World is fast paced and it is hard enough for anyone to have a relaxing and rejuvenating vacation, much less take time to work through grief or loss.
And of course, where past generation's have worked through their loss emotionally, our generation and the younger ones grieve through lawsuits and the pursuit of a monetary amount that will replace the pain.
This is not meant to be negative--just more reality based of now. so, yes, I think meds along with therapy help.

Midwife with a Knife said...

clink: Yeah, the NYT article seemed to imply that people who aren't depressed are being labled with and treated for depression (although I agree with Dinah, these people aren't being bludgeoned on the street and pulled into shrinks' offices and then treated for depression against their wills; but sometimes they're being referred by their obstetrician a few months into the aftermath of a perinatal loss or after their gynecologist (who they saw for poor sleep or lack of libido) becomes suspicious that they're actually depressed 6 months after a divorce).

The psychiatrist on talk of the nation(Regier, maybe, was his name), made the point about treating depression on the basis of severity not on the basis of whether or not someone's also grieving. Link:
(Blog of the Nation, the blog of NPR's Talk of the Nation; the piece is about halfway down the page). It also seems to me that part of the problem that the study probably correctly points out is the use of screening checklists. Even in gynecology, actually taking a sexual history is much better than just using those forms that patients fill out.

Just out of curiousity, is there a time limit at which grieiving should be done and depression begins? And can't loss/stress precipitate the first episode of a major depression? And how do you tell the difference? (I'm really just curious, I'm going to continue to try to send these women to my shrinky colleagues.)

Anonymous said...

I talked to that guy on the phone recently (Dr. Regier)...does that make me famous??? (please, please)

MWWAK, I know you asked Clink, I'm just chiming in here.
Time limit? The world starts expecting you to move on after 6 months. Seems to me that people start to feel better around 18 months, maybe. Often, if you ask, people are still grieving for years and years. That's not normal, but it is. What's normal? Oh, never mind. Usually the sleep and appetite issues resolve in a year, how's that. It's not unusual for people in non-patient populations to drop a fair amount of weight after a major loss. The short answer: No Time Absolute Time Limit. How do you tell the difference: I'm still working on it. In Grief, people don't have lowered self-esteem, don't think they're a bad person, and any guilt is focused (...I should have brought him to the hospital sooner, should have done such and such, but not I'm the cause of world war II), and resolves with time.

Suicidality is never normal.

You're better off over-referring then under-referring. It's not the end of the world to talk to a shrink for a few sessions even if one doesn't have a mental illness but is merely grieving. Clink can disagree if she wants.

I used to think people got offended when their docs told them to see a shrink-- lately I'm struck by how many referred patients express gratitude that their primary care doc got them hooked in with some help.

Roy: why does increasing endothelium on vascular walls increase neuronal growth? Someone please send me back to med school...

Gerbil said...

Clink: I found four, each of which (I'm still impressed by this!) aligned very closely with exactly one of the four proposed self-injury disorders in the literature.

I didn't ask about about ingestion of cell phones or other non-food objects, though. IMHO it's tough to separate that from factitious disorder...

And yes, I have a lot of brains in my fuzzy little head. But, you know, size doesn't matter ;)