Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Saturday, July 21, 2012
DSM-5: More Dynamic?
Over on KevinMD, Dr. David Kupfer has an article up called DSM-5 Will Capture the Dynamic Nature of Mental Illness. Huh?
Let me start by saying that Dr. Kupfer has been an influential person in my course to becoming a psychiatrist. In the 1980's, he ran a program called The Mellon Fellowship in Psychiatry for Undergraduates, where he paid undergraduates to spend 8 weeks in Pittsburgh doing research and observing clinical settings at Western Psychiatric Institute and Clinic. I was a Mellon fellow. I hit medical school knowing I wanted to be a psychiatrist and with a notable head start on the other shrinks-to-be.
But I don't see how the DSM-5 captures the dynamic nature of mental illness. From what I can tell, it's like the DSM-5: checklists of symptoms that either box you into a category or exclude you from it. The DSM is a very useful tool for researchers --- it lets them be sure that when they test a medication on a group of people with "depression," that those people have a similar condition. Clinically, it's not that useful. I'm sorry, you're suffering terribly but you only have 4 symptoms and you need 5, so you don't have an illness and so I'm not prescribing a medication for you, not coding it on your statement so you can get reimbursed, and you'll need to leave now. Oh, that's not how psychiatry works.
Psychiatric disorders are dynamic in nature. People get better and you never hear from them again. Or years later, they call and say "I saw you way back when, I stopped taking medicine because I felt better, I've been well for years, but now I'm having trouble and I'd like to come see you again." Sometimes they have a recurrence of the old problem, sometimes they're having a rough patch that has nothing to do with their past issue. Some people have chronic illnesses and stay chronically symptomatic, others don't. We know surprisingly little about the course of mental illness. And when you start to talk about developmental illnesses, we really know very little. I can't tell you how many teenagers I've known, or known about, who've been horribly distressed or disturbed, who clearly meet criteria for major mental illnesses -- often life-threatening-- who benefited from treatment (medications and psychotherapy), but who seem to age themselves out of their problems. Was it an episode/s that will recur in years to come? Or was it just a bad teenage phase? Of course these kids need treatment, but if we're making diagnoses dynamic, we need to acknowledge that we don't know if these kids have lifetime illnesses or transient phase of life issues.
I'm not so hopeful that DSM-5 is going to prove to be a clinically useful tool. Your thoughts?
Posted by Dinah on Saturday, July 21, 2012
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It is a little hard to imagine a giant compilation of checklists as being dynamic...
Though I have heard they are expanding categories and at least attempting to more clearly define different subtypes of illnesses. So I guess this is what he could have meant by more dynamic?
Though I am disappointed that learning disorders is getting so little attention. That part of the DSM is so clearly deficient that I am shocked they are not making more of an attempt to refine it. They aren't even going to include Nonverbal Learning Disorder. So what do NVLD types all get lumped under? Learning Disorder NOS? I don't think the jury is still out on that one. I'm pretty sure it's real.
You hear me psychiatrists?! Start asking the DSM gamemakers to put a little more effort into learning disorders.
I find it disturbing that learning differences are included at all in a manual of mental disorders. Two of my own children have learning differences but because we did not pathologize those as disorders and because they received interventions and supports (none of which required a psychiatrist or clinical psychologist) they are both doing well as adults. Post school, no one would even know they had any issues. I understand that anxiety and depression can be associated with learning differences, but that is more a function of how we label children and expect each one to fit into the same little box. It can also be a function of failing to understand how a child learns and not understanding how to bend the teaching to meet the child, instead seeing the child as defective.
I am for the medicalization of learning differences, because there really isn't a set national standard for what constitutes a learning disability.
In CA, schools are allowed to set their own standard for what constitutes a learning disability. Other states are different depending on their state legislature. A kid who was dyslexic in high school can be told he doesn't have it in college (or vice versa) because he didn't fully meet the school's criteria.
When I was in public school I didn't qualify as learning disabled because I was labeled emotionally disturbed--even though I tested as LD. According to their standards, a child cannot be labeled with a learning disability if he or she has been diagnosed with a mental illness (like depression). However, the college I went to believed learning disabilities are NOT caused by mental illness, so I qualified for accommodations as a learning disabled student after they tested me. Other colleges actually demand that you be diagnosed by an MD or a psychologist if you want accommodations. I hear New Mexico is amazing. If you are diagnosed with a learning disability at any age (by school, MD, whoever), then you qualify for accommodations for the rest of your life. But that is only because New Mexico has a statewide standard for LD. They also will not exclude you from the diagnosis if you have a mental illness. Even something as potentially benign as ADHD can exclude you from a diagnosis, because ADHD could have caused the low IQ scores.
Quite literally, if you got a divorce, and your kid scored as LD on an IQ test performed by a school, the school can use the information against you and say that your kid underperformed from the stress of you having gotten a divorce. If you attempt to get a second opinion from outside the school, the school can tell you they won't accept the diagnosis because they have a specific standard for LD.
Though everyone is different. My GP thinks LD can be caused by ADHD and that is the cause of my LD. But then I have met other healthcare professionals who believe they are absolutely two separate conditions.
Also, the accommodations in a public school in CA are really different if you have an LD diagnosis. ADHD is actually cheaper for them to accommodate. If you have LD they have to accommodate you into your 20s and it's all really expensive. ADHD is more likely to get reimbursed cuz the school has to do less, so they have incentive not to diagnose LD.
It's not just LD though. The schools are all trying to save money right now. Bad economy. I have a friend with a nephew who has autism. They literally had to threaten to sue the school in order to get him help. And I don't mean this kid had Aspergers. He has full blown autism. They hired a lawyer, brought him to an IEP meeting, and suddenly the school could give that kid every accommodation under the sun.
Personally, I just want LD to be standardized and nationally accepted under DSM guidelines just so there can be some kind of national standard.
Thank you for the regional info. In our locale, LD is not medicalized. No MD need be involved. An educational psychologist can provide a report and based upon that,children in school and adults in college can receive accommodation. I view that as an ideal situation and we are lucky. Not all schools are as good as others but at the post secondary level, most are excellent in the range of services to students with LD. I think it is an injustice to have to medicalize LD in order to receive supports and that is why I oppose its inclusion in the DSM. I understand why disagree but I don't get the sense that you believe it to be a mental disorder any more than I do. I find it sad that legislation can put anyone in the position of wanting their LD to be listed in the DSM.
But for a learning disability to be diagnosed by psychologists, presumably there is some DSM-like list of criteria to standardize what the heck this learning disability is. Why not include these under the DSM? Doing so doesn't mean only an MD can make the diagnosis. I wonder whether you are (over)reacting to the idea that both LDs and Big Scary Diagnoses like schizophrenia might be found in the same book, or that someone with a LD is "mentally ill" because LDs are included in the DSM.
I am not overreacting. I have a big scary diagnosis. My kid has an LD, and they do not belong in the same book.
Educational psychologists, not MDs, are qualified to diagnose LD. They use a combination of IQ tests and standardized achievement tests, as well as other psychometric measures to formulate a "diagnosis" and make recommendations. If the psychologist suspects that there are also mental health issues, they will recommend that the person see a person for that and THEN it may or may not be appropriate to be handing out DSM labels.
For better or for worse, LD is in the DSM. Psychologists use the DSM to diagnose people with any kind of disorder that they are trained to diagnose, and at the very least some of them are trained to conduct psych testing and diagnose LD.
MDs do diagnose LD after appropriate testing has been done. A psychologist may perform the testing, or whoever is trained to conduct the test, and the MD may diagnose LD if he or she receives the scores. I know this because I went to a college where they could test for LD but were not allowed to diagnose it. I was told my GP could diagnose it if I gave her the scores. When she saw my test scores, she did appear to know how to interpret them. MDs don't conduct the testing, but they can interpret scores and diagnose.
You are right that diagnoses don't help much - maybe a parent needs them for his kid so he can get accomodations and interventions, maybe help for medication but diagnoses which simply describe symptoms ignore the conditions and underlying factors giving rise to the problems. I prefer working with Ross Greene's assessment of lagging skills and unsolved problems guide list
I think the phenomenological systems starting with DSM-3 or 3 TR are enormously helpful and useful. The use of entry or required anchoring symptoms followed by b a list of possible but not absolutely required except as to number of symptoms is a brilliant device. It separates people into who is likely to respond to what therapy based on indications and published reports. For instance in adolescent psychiatry the best results in bipolar disorder are found with the 'antipsychotics' for instance see the paper by Biederman et al., http://www.ncbi.nlm.nih.gov/pubmed/15685125?log$=activity
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