Thursday, December 18, 2008

The New Book

The DSM-IV is the standard for diagnosing psychiatric disorders. It lists the disorders and what symptoms a patient needs to have to 'meet criteria' for that disorder. It reads a little like a Chinese Menu-- if you have one/two/however many symptoms from column A and a certain number of symptoms from column get the idea. What's interesting is that it's the Diagnostic and Statistical Manual of Mental Disorders, but there's nothing Statistical about it. The criteria are decided by committees, not by experiments or long-term studies that follow prognosis, not by response to medications, not by the presence or absence of a gene or chemical or abnormal brain structure. Yes, we talk about the genetic predisposition to illnesses and chemical imbalances, but they're all assumed (sometimes by rather strong evidence). We treat brain disorders, but we don't know the precise biological etiology of any psychiatric disorder. (Okay, Huntington's Disease, but that's considered a neurologic disorder that has associated psychiatric manifestations).

So the committees that define the disorders (not statistically) are faced with all kinds of issues, particularly around the inclusion or not of many the things we talk about here at Shrink Rap. Is criminal behavior a psychiatric disorder? Binge eating? Homosexuality (-- homosexuality was removed as a psychiatric disorder some time ago).

So what's a disorder (there are apparently 283 ways to be mentally disordered) and how do we arrive at these decisions? There's the politics of it all, there's insurance reimbursement implications, and I imagine the pharmaceutical companies care how the cards fall. The committee members have to limit their income from pharmaceutical companies during the process of DSM work. To further the controversies of it all, the process has been questioned in terms of how transparent it is and who has access to what goes on in the meetings.

In yesterday's New York Times, Benedict Carey address some of these issues in "Psychiatrists Revise the Book of Human Troubles:"

The scientists updating the manual have been meeting in small groups focusing on categories like mood disorders and substance abuse — poring over the latest scientific studies to clarify what qualifies as a disorder and what might distinguish one disorder from another. They have much more work to do, members say, before providing recommendations to a 28-member panel that will gather in closed meetings to make the final editorial changes.

Experts say that some of the most crucial debates are likely to include gender identity, diagnoses of illness involving children, and addictions like shopping and eating.

“Many of these are going to involve huge fights, I expect,” said Dr. Michael First, a professor of psychiatry at Columbia who edited the fourth edition of the manual but is not involved in the fifth.



Dr. Pink Freud said...

That the DSM is based on little empirical evidence speaks volumes as to why the different diagnoses have poor interrater reliability, and the disorders (in particular Schizoaffective D/O) have varying degrees (and in some cases quite low) of validity.

That the DSM is based on the "Chinese menu" approach to pathology may not necessarily be a bad thing. With a nosological classification system, limited understanding of brain function, and etiology of illness, we are left with treating the separate symptoms, and never really the disorder as a whole.

I rather like the idea of treating symptoms over disorders: it might actually reduce the experience of stigma. Diagnoses are only constructs used to simplify the process of understanding. I think emile kraepelin's approach was right on. He viewed mental illness as a spectrum, lacking in many instances, for al intents and purposes, strict delineation between disorders. Think about it, a hundred plus years later, and we're back to the basics.

Anonymous said...

This also highlights the notion of recovery - of which I was reminded by a client earlier in the week. The client, a young woman diagnosed with borderline personality who has been relatively asymptomatic for 12 months, asked "why does the medical record still say BPD when I've been really good for a year?" It's a reasonable question...

If one orders from the menu (aka diagnosing a PD) then one no longer meets the criteria, (i) were your eyes bigger than your stomach and you've over ordered? - axis 2 instead of axis 1, (ii) do you send the diagnosis back to the kitchen as being ill-prepared? - DSM-V, (iii) do you complement the chef? - removing the label and celebrating recovery, or (iv) simply stick with the self serve buffet? - symptom treatment.

Too hard ... I'll just order in.

Anonymous said...

So what good is the DSM? It's a label that sticks forever and it's made up!

FooFoo5 said...

I am interested in the source of Dr. Pink Freud's justification for indicating "poor interrater reliability." Personally, as I've written about on many occasions, I couldn't agree more. But, having raised this same question at a "Grand Rounds" with forever nameless members of several DSM "committees," specifically in regard to GAF scores, in my opinion the be-all-and-end-all of "empirical foolishness" (Please clarify the significant differences between 44 and 46). They were appropriately outraged at the insinuation, swore by the interrater reliability, and suggested I needed to brush-up on my "data." Hearty ***-kissing chuckles were noted, probably by others dying to get on a committee.

For forensic purposes, it seems reasonable to be as "strict" as possible in providing an accurate diagnosis. Forensic favorite: NOS. For other purposes, I know many many colleagues who "cloak" diagnoses so as not to stigmatize, and I suspect not to "alert" the patient (e.g. personality disorders).

I have yet to see a diagnostic guide to, for example, breast cancer developed in "secret" or by anything but empirical, objective data. In the case of the DSM, until it become a "statistical" manual, it is merely a billing menu and a paper-weight.

Anonymous said...

Is it really that difficult to find a hundred or so shrinks in this entire country that have NO attachment to industry to work on this thing?

Not only would we (hopefully) eliminate the elevation of industry's interests above all else, but the shrinks on the committee would actually have some experience working with real patients.

When was the last time that any of the industry mouthpieces actually treat a patient that was not enrolled in a study?

I don't think I want these people writing our book.

alfavita y2k said...

Let's see, an individual is calleld "Homosexual", when his mind in an unnatural state under deep hypnosys, a homosexual is someone who was born in a dysfunctional family of degenrates, who hypnotised him in childhood in order to make him have unconscius sex against hiw will with other degenerates. WHich is also called "Abused by parents".

In this state of mental disorder inducted by childhood abuse and kidnapping, that provokes uncounscousness, and complete loss of rationality, logical brain functions, or natural inborn instincts or natural aquired reflexes, is to consider as same as attemted murder in terms of legal psychiatry.

Whoever is pretending thta being a homosexual is a sane naturla state of mind and body, must be imprisoned in criminal psychiatric facility and keept forever inside.

Anonymous said...

I liked all comments but the last one.... Not just the letter jumbling....

Personally I don't believe awareness works in a way that can be learned from books whatsoever. For new experiences in real life transform how we read and process the material.

I've seen photo's of me from the days of anxiety neurosis, there's nothing to see, the camera lies. Same for depression. Oh and I mean depression, not reactive bereavement... On top of this, I am yet to meet a psych who talks in the language of first-hand experience. I've been told I'm well when I know I'm not, I've been told I'm ill when I just haven't slept. There has never been a contiguous understanding of the real-time sensation.

Solipsism is running the asylum...