Wednesday, March 03, 2010

Saving Normal

Allan Frances chaired the APA task force that created DSM-IV. On Monday, he had an editorial in the Los Angeles Times called "It's Not Too Late to Save Normal."

Dr. Frances writes:

The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day -- despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.

The manual, prepared by the American Psychiatric Assn., is psychiatry's only official way of deciding who has a "mental disorder" and who is "normal." The quotes are necessary because this distinction is very hard to make at the fuzzy boundary between the two. If requirements for diagnosing a mental disorder are too stringent, some who need help will be left out; but if they are too loose, normal people will receive unnecessary, expensive and sometimes quite harmful treatment.

Okay, I have a confession to make here: I don't keep a copy of the DSM in my office. I own an edition which I've opened a couple of times while writing our book. I don't care what the precise diagnostic criteria are: mostly I know them, but I'm left with the fact that if you wander into my office saying you're tormented and suffering or having trouble functioning, I'm going to treat you. And if I prescribe medications, it's mostly based on symptoms. Totally? No, because if there's history of mania (I know those symptoms) or any sense that the diagnosis might be bipolar disorder, I'm going to go pretty gently with the antidepressants, just because I've notice that people with tendencies towards mood instability (whether or not it meets criteria for full mania) do better if the antidepressants are kept to a minimum. I hear we over-diagnose, but I'm going to comment that absolutely no one has ever come to see me for simple, uncomplicated grief or a normal reaction to a stressor-- people just don't define this (and let's hope it stays that way) as a reason to run to a psychiatrist. And everyone's favorite diagnostic complaint: Shyness vs. Social Anxiety Disorder. 18 years of practice and how many patients have come with a chief complaint of isolated social anxiety? Zero. And how many patients in my practice carry the diagnosis of Social Anxiety Disorder? Zero. Over-diagnosis of mood and anxiety disorders in general? Of course-- maybe we're treating people who previously would have just suffered. Or maybe we're forced to assign a reimbursable diagnosis because V Codes (phase of life and relational disorders) can't be reimbursed. It all gets to be circular reasoning.

So who's placing bets on whether I purchase the DSM-V?


SteveBMD said...

I agree with you, Dinah. The manual is useful for research purposes and as a whipping-boy for the anti-psychiatry contingent, but for very little else.

Like you, I try to understand why and how the patient is suffering, and treat the symptoms first. If I can identify a root cause (chronic depression, bipolar disorder, substance abuse, a personality disorder, etc) I'll treat that, too, but that's not usually apparent at the outset, even if I do give them a 296.33 or a 295.70 for billing purposes.

What I hate is when people insist upon a certain diagnosis and that the treatment correspond to that diagnosis--- for instance, the colleague of mine who complains that patients diagnosed with schizophrenia are taking Depakote ("shouldn't that be schizoaffective?"), or those who agonize over calling something bipolar vs. unipolar depression (because one "should" be treated with a certain atypical alone, while the other requires an antidepressant, too), or the insurance companies who insist on a particular diagnosis to cover a certain medication. The examples of over-reliance on the DSM are endless.

In my practice, I'll go with whatever works, which sometimes means no clear diagnosis and no meds. (Funny how often that actually ends up working best!)

bouncy castle hire weston-super-mare said...

WOOAH - I'm not going to be as long as above... I SAY GET DSM-V !!! Keep up the great work , from your man over in UK - Ninja !: )

the alienist said...

I don't think that my experience is terribly abnormal, but I do have people without psychiatric illnesses come to my office for evaluation. Society does not seem to realize that all distress does not mean illness and that there are even normal ways to be sick.

While I agree that the DSM is not a perfect document (or even close to a perfect document), it does provide a way of looking a abnormal behavior in a systematic way. For some patients and doctors, this is a comfort. For others, it is a distraction.

Anonymous said...

The alienist brings up a point that I've often wondered about which is how society is defining distress these days. Obviously the increase in medication is due to patient demand. I wonder if the pharmaceutical advertising we're saturated with on a daily basis is causing people to redefine distress/discomfort/life. I feel down in the dumps, so maybe I have this chemical imbalance I hear so much about, then off to the physician's office for meds. People are coming in asking for Abilify because they saw an advertisement for it. I wish we didn't have pharma ads. I think they're a big part of the problem.

moviedoc said...

I was really hoping for some more biologically based criteria in 5, but we just aren't there yet. 5 almost seems more like 4-TR2. Maybe we should wait and hope for bio markers. We can almost diagnose "antidepressant reactive disorder" now. Of course if Akiskal had his way it would the the Diagnostic and Statistical Manual of Bipolar Disorders, and they would just be numbered 1-247 or so.

Be sure to put in your 2 cents worth at the dsm 5 Web!

Dinah said...

StevebMD: Thanks!
Ninja person from UK: hi.
The alienist: So what? I don't think it's the "usual" for every person with a distressing event to run to a shrink, but you're allowed to go get an Xray if your arm hurts to r/o fx.
Why can't you go to a psychiatrist w/o an psychiatric disorder to : 1) be evaluated and be sure you don't have one if you or your loved ones wonder, or 2) use psychotherapy as a means to process a difficult time, gain some insight &/or comfort, or increase coping mechanisms.
Why do you have to know if you have a disorder before you walk in the door--- oh, but you can reimbursed for r/o fracture, you can't get reimbursed for r/o mood disorder. I didn't look, does DSM5 leave us with Adjustment Disorders?

So if someone comes in with pain, we think it's not an illness, they insist they want to try meds, we tell them it's not an illness and the meds have risks, they say they're suffering and want the meds anyway, we prescribe them and they take them a few months and feel better: Is that horrible? Isn't that empowering the patient to take an active role in their care? If we give a medication without informed consent, we're bad, and we believe that patients have the right to say, "No thank you, I've decided it's not worth the risk" why shouldn't we let them say, "I understand the risks, I understand that it's not indicated, I understand that I may be farting with evolution or my ability to grow from my pain, and I want the medication anyway" (let's keep controlled substances out of this discussion)... It's a crutch, yes, but is the assumption that if you suffer through your pain that you'll be stronger and learn to cope better in the future an accurate one? And if the x-ray shows that leg is fractured, well we'll let you have that crutch.

Moviedoc: what dsm5 web?

Anonymous said...

Possibly talking about

Anonymous said...


Anonymous said...

Steve MD, what you refer to as the anti-psychiatry crowd doesn't need the DSM for its whipping boy. When antidepressants are unreasonable prescribed for everything under the sun, that is enough to reasonably anger people.

Anyway, I am not antipsychiatry or anti any med specialty. But as one who has been greatly harmed by psych meds, I am tired of alot of your colleagues using a one size fits all mentality and not listening.

In my experience, psychiatrists like you are rare.

Dinah, speaking of not listening, I don't feel you are hearing why people are angry and why these articles are popping up. As one who has suffered great adverse affects from psych meds, these comments "I understand that I may be farting with evolution or my ability to grow from my pain," you don't get it.

Of course, it isn't horrible if someone feels better. You're asking a rhetorical question.

The issue is that people will start feeling better and not giving a damm about anything as the woman mentioned in dealing with her abusive husband. But most of your colleagues will blame that on depression because you can't trust people with a mental illness label, right?

Finally, I keep emphasizing this point on various blogs and I will say it again - There is no five year study that proves the effectiveness of antidepressants. Sorry, 8 week studies don't qualify. So anything you say about your patients getting better is strictly anecdotal.

I had to mention that because it get thrown in my face (not here) that when I mention that I know several people like me who have been greatly harmed by meds, it is all anecdotal. Fair is fair.

Novalis said...

Dinah, regarding your post itself, I agree with you that practically speaking, that is how a lot of psychiatrists work (myself included), by treating symptoms.

The drawback of this is that it gives up on any intellectual legitimacy to the field (there may still be considerable moral legitimacy to alleviating suffering whatever its source). The dermatology joke is: if it's dry, moisten it; if it's moist, dry it out. Is psychiatry ultimately any better? If it's too high or too fast, lower it and/or slow it down; if it's too low and slow, raise it and speed it up.

Another problem is that patients crave not only a name for their suffering but also a prognosis. Without some kind of consensus regarding disorders with a more or less recognizable natural history, how can we give patients any sense of what to expect from the future? I don't pretend to know the answer, but it seems unsatisfactory nonetheless.

The question ultimately is whether psychiatry as a discipline really has any specific expertise, beyond, that is, good intentions and the occasional recoveries that come about as a result. Sometimes I think that our primary role is to *bear witness*, while administering largely palliative medications along the way.

Anonymous said...

Novalis - it may be that sometimes your role is to "'bear witness' and administer largely palliative medicines along the way," but (1) that is true of many physicians - patients come in all day long looking for someone to listen to their complaints, especially some of the older, lonlier patients - listening is part of the job; (2) some patients truly need a psychiatrist and the medicines you prescribe; and (3) even if psychiatrists do not have any special skills, the fact that they went to medical school will give some patients more comfort or confidence than they may otherwise have with, for example, a social worker.

The Alienist said...


I'm not sure how to take your reply to my comment. I was simply commenting on psychiatry's ability to educate people about their emotions and on our ability to resist the tendency of society to pathologize normal experiences. I never said that people couldn't go to doctors for whatever reason they want. Of course they can, though they may not get what they are wanting from their doctor every time. If this is the 20th time they have shown up with arm pain and demanding an x-ray, it might not be wise to expose them to radiation again.

On the other hand, I do think there are problems when we prescribe medications for some patients without a clear indication. I have treated some patients with an extreme external locus of control who have not taken responsibility for their own lives except to demand every new medication that comes out. Simply giving in to demands for prescriptions allows them to perpetuate their problem instead of solve it.

I agree with you about the problems of treating people without DSM-IV diagnoses. I have had sessions that were not paid for by insurance because I was not able to put the right number down in the diagnosis area.

moviedoc said...

Thank you Novalis for at least inadvertently bringing into this discussion two aspects neglected by Shorter, Sally Satel's excellent review of Horwitz, and even Alan Francis: comparison of psychiatry to alternative medicine and a general medicine. I recall the dermatology in a nutshell adage as having three arms:

The naturopathic (placebo or dangerous) arm: it's wet dry it.

The homeopathic (Homeopathic remedies essentially consist of water.) Arm: if it's dry wet it. (My dermatologist recommends Crisco -- off label.)

The allopathic arm: when in doubt use steroids.

You asked whether psychiatry is any better. I think a better question is whether general medicine is really much better than psychiatry. As far as I know we may be the only specialty with a diagnostic manual and criteria for diagnosis with the possible exception of fibromyalgia which some might argue should be classified as a psychiatric disorder.

And with all the claims that psychotropic drugs are no better than placebo, what about St. John's wort, et al?

Ultimately I agree with stevebMD: whatever works.

Dinah said...

Actually, my "is that horrible?' tirade wasn't meant as a tirade but as a serious question. I think I got the tone wrong, but I, too, play with these issues. Over and over, I see patients want meds and want to stay on them and mostly I hear "I never want to feel that way again."

Complacency is not good, and I sometimes I wonder if people aren't content when they shouldn't be. But more often I see people paralyzed in their distress who become mobile once they are feeling better.

Oh, and why is dermatology bad?

At the end of the day, we're all just slobs hoping that we're doing something useful that has a positive impact on people. It's hard because the landscape changes all the time, we believe we're helping, we learn that a med prescribing or a technique we believed was right (think cultures where a cancer diagnosis is hidden from the patient), we learn these things are bad or wrong or harmful or no longer culturally sanctioned, and we alter our behavior accordingly. What bugs me is that tone of it all assumes that we meant to cause harm from the outset.

moviedoc said...

No one said derm was bad.

I'm not a slob, and neither are you.

I don't think anyone believe we are out to do harm from the outset, but rather that we exploit misery for financial gain, that we are charlatans. I think psychiatrists believe in what we do, partly because we believe the best science we have (which may not be all that great) supports us better than it does "alternative treatments."

The Alienist said...

It is difficult being demonized for trying to help suffering people. I think moviedoc is right when he says that most people think psychiatrist just prey on the suffering of others, but let's not forget the Scientologists who seem to honestly believe that we are evil and intend to harm people from the outset.

Anonymous said...

@ Anon.. Oddly enough, I had a psychiatrist refuse to see me because I didn't want to take Abilify. Furthermore, he told me that if I didn't take it, I would kill myself. That was over a year ago, and I'm fairly certain that I haven't done anything of the sort. In fact, I quit smoking, so I've actually done the opposite.
I prefer not to take medications until they've actually been tested by somebody besides the company standing to make a profit off of them.

On the topic of "invented diagnoses" I don't see why that's a problem. Sure, ODD is the very picture of adolescence, but some people require therapy in order to survive just being that age. I don't see why naming a disorder for "difficult adolescence" is a bad idea unless professionals take it too far.

Anonymous said...

Movie doc
on the subject of Fibromyalgia. As someone who has this syndrome I see it as belonging to the Rheumatology field and a close relative to Athritis.
Even though the meds are Psychriatic.

Paperdoll said...

Hi Dinah,

I am enjoying your recent posts. I think the numbers of responses of late indicates that the topics you are choosing are engaging fellow medical professionals interested parties and patients alike. Bravo!

I love any topic that includes the word "normal". It brings robust debate.. I say bring it on.. What is normal, who defines it, what is the range of normal.... and then there must be some limits to the range of normal, if abnormal can be defined.

The bell curve and 95% confidence limits or 2 standard deviations beyond the mean are good in theory. Great for mapping your child's head circumference or your serum potassium. Numbers work really well in this continuum.

I find it more difficult to see how more subjective things are placed into this sliding scale. When we were cavemen / women in loin cloths, survival, the next meal, shelter and warmth are big deals. OK if we take food and shelter out of the equation, and I realise that these are still really big issues for some folks. The fact that we don't feel good, we can't enjoy the simple pleasures of life, we feel sad / blue /down are big deals. It's all relative.

The DSM, like the AJCC/UICC cancer staging manual in its 7th edition in 2010, is updated every 6 -7 years to reflect current circumstances. The 6th edition is out. Get with the times. Your old DSM reflects a time no longer in existence. Move on or be a dinosaur. There is a consultation process. If you have a view, get in there. If you hang back and wait for the white paper, an you don't like it: well you had your chance to had your say. If you had a passionate view get in there, express it. Those who don't get involved can't complain after the fact.


I've never been a Blue Calm Sea, I have always been a Storm: Not all the prayers in the world could save us.I loved you from the start...I should have known from the first that I'd be the broken hearted.... Save us....Every hour of fear I body tries to cry... Not all the prayers in the world could save us..... said...

Oh, I didn't say and I wish I did.

Novalis, it's so nice to have your comments.

Hope your new site is going well. I don't get there as often as I would like to, but I loved your old site very much. Can yo give us a link?

moviedoc said...

Anon: but what make fibromyalgia belong to rheumatology? just the fact that it involves physical pain? Even many rheumatologists seem skeptical, and one I know tells us to look for a history of "abuse" and get the patient into "counseling." My cousin, who used to take narcotics for the pain, says his was cured by meeting his wife. And yet I as a psychiatrist do not feel qualified to diagnose or treat it. It's a great example of the challenges we face in classification even outside of psychiatry. And as for the drugs being "psychiatric" almost all drug with which we treat psychiatric disorders (or symptoms) have uses, if not indications, for what most would agree are non-psychiatric disorders.

Anonymous said...

Movie Doc, go to and look for comment 176.

It is by someone who said her doctor was very skeptical of the diagnosis until he saw people that he considered very psychologically fit getting the condition. He changed his tune.

It greatly bothers me as someone who has never had the condition that doctors are so ready to make something psychological they don't understand. I am not saying you're doing it but many of your colleagues are.

Anyway, after seeing some what I felt were some very cruel comments by physicians on that blog, I don't think psychiatrists alone should be criticized for not getting it. I think medicine in general has a problem with this.

Regarding using psych meds for non psychiatric reasons, I hope doctors are disclosing to their patients that there may be withdrawal issues in getting off the meds. Cynical me says it isn't happening.