Blame the DSM?

In the Washington Post, April 27, 2012, "Psychiatry's Bible, the DSM, is doing more Harm than Good," Paula J. Caplan writes:


About a year ago, a young mother called me, extremely distressed. She had become seriously sleep-deprived while working full-time and caring for her dying grandmother every night. When a crisis at her son’s day-care center forced her to scramble to find a new child-care arrangement, her heart started racing, prompting her to go to the emergency room.

After a quick assessment, the intake doctor declared that she had bipolar disorder, committed her to a psychiatric ward and started her on dangerous psychiatric medication. From my conversations with this woman, I’d say she was responding to severe exhaustion and alarm, not suffering from mental illness.

Caplan goes on to express her concerns with psychiatric diagnoses, the DSM, the problems with these labels that lead to the use of dangerous medications.  Oh, we've been here on Shrink Rap before, see "Diagnostic Labels That Change Lives". 

Caplan continues

In our increasingly psychiatrized world, the first course is often to classify anything but routine happiness as a mental disorder, assume it is based on a broken brain or a chemical imbalance, and prescribe drugs or hospitalization; even electroshock is still performed.


According to the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), which defines the criteria for doling out psychiatric labels, a patient can fall into a bipolar category after having just one “manic” episode lasting a week or less. Given what this patient was dealing with, it is not surprising that she was talking quickly, had racing thoughts, was easily distracted and was intensely focused on certain goals (i.e. caring for her family) — thus meeting the requisite four of the eight criteria for a bipolar diagnosis.
When a social worker in the psychiatric ward advised the patient to go on permanent disability, concluding that her bipolar disorder would make it too hard to work, the patient did as the expert suggested. She also took a neuroleptic drug, Seroquel, that the doctor said would fix her mental illness.

Caplan goes on to say that because of the existence of a psychiatric label-- one she contends is wrong-- the patient lost her friends, her marriage, her home, her self-confidence, her wealth, was forced to move across the country to somewhere she was isolated, and the six weeks she spent on medication (presumably Seroquel) left her with a condition that may someday leave her blind. 

Mental health professionals should use, and patients should insist on, what does work: not snap-judgment diagnoses, but instead listening to patients respectfully to understand their suffering — and help them find more natural ways of healing. Exercise, good nutrition, meditation and human connection are often more effective — and less risky — than drugs or electroshock.


Caplan, a Harvard psychologist, goes on to discuss a complaint she is helping to file against the DSM editors on behalf of 10 patients who were misdiagnosed. "Psychiatric diagnoses," she concludes, "are not scientific and they put people at risk."
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Where do I even begin?  Please, please, I don't know the patient, I only know the presentation given, and I'm going to be very sarcastic, because the way it was presented struck me a ridiculous and it distracted from some valid points that might have been made if there wasn't the Evil, Idiot Psychiatrist Theme with a sensationalist tone.  Shame on the Washington Post for printing this.

Okay, so   I couldn't quite follow the case she presented, at first it sounds like the patient went to the ER with symptoms of a cardiac problem, or exhaustion, or a maybe a panic attack.  Perhaps, but some imbecile ER doc did a check list of symptoms, told her she had Bipolar disorder, and without even listening to her,  weighing other options, or taking into consideration the context of her life,  sent her off with Seroquel and a recommendation for  therapy.  This misdiagnosis then destroyed  her life, because  why would her husband and friends stick with her if she's got bipolar disorder?  What better time to leave your wife then when her grandmother is dying, she's stressed out and sick?  So she went to the ER because she was tired and her heart was racing.  I think they see this all the time...I think they do an EKG and perhaps make sure the patient isn't having a heart attack or arrhythmia, and if they think it's anxiety, the patient gets a dose of a benzodiazepine, and gets sent home.  Okay, but it's an ER and the docs are rushed and focused on what the patient needs now.  They make wrong diagnoses all the time, and it's not just psychiatry, and it's not just  because the doctor is sitting there with the DSM or has memorized the hundreds of possible diagnostic criteria.


Okay, but it turns out that she was on a psychiatric ward.  You can't get admitted to a psychiatric ward because you're tired, with racing thoughts, a fast heartbeat, talking fast and being distracted.  Pretty much, you need to be a danger--, suicidal, or having severe hallucinations or delusions, or be in extreme distress in some way.  This was a wealthy patient who could afford outpatient care.  All I'm sure of, is there is something more to the story. 


Finally, the patient was admitted to a psychiatry unit, so presumably there was a second doctor who met with the patient and a treatment team that observed her behavior for a few days.  Okay, I've stories of really lousy inpatient care, and I do believe the diagnosis could still be wrong and the treatment that was recommended might be wrong, or helpful at the moment but not necessary for the long-term, but I don't buy that a misdiagnosis let to the complete demise of this patient's life and a need to move across the country.  These are the types of problems one sees as a result of the behaviors a person might have because they have a mental illness, perhaps one such as bipolar disorder.


So I don't know the patient, or the diagnosis.  But I do know that the entire premise for this article is based on the idea that the patient was simply tired and stressed and perfectly normal and did not have a psychiatric disorder (the author tells us this) and this label alone destroyed her life.  The reader is not allowed to even entertain the idea that the patient had a psychiatric disorder-- that maybe the psychiatrist did get some history and make reasonable observations, and the patient really did have bipolar disorder? (Obviously, I don't know this).  There's no mention of a review of the records, discussion with family, interview of the doctor, Caplan is telling us her impression based on the patient's report only.   Maybe the patient had panic disorder, or a personality disorder, or even an adjustment disorder (perfectly possible given the stresses involved).  Oh, but then she took a bum recommendation to go on disability, and she got it!  I've seen really sick people not get disability.  It takes a lot of documentation and the government looks for ways to avoid paying this-- you don't get disability for having a psychiatric diagnosis, you have to be disabled by it.  So, somehow, this patient who  was simply exhausted and stressed, with No Psychiatric Disorder, per Dr. Caplan, managed to get admitted to a hospital and get disability benefits.


There were some valid points Caplan could have made.  The DSM is not a 'scientific manual.'  Personally, I don't find it terribly helpful in clinical practice.  I don't keep a copy in my office (I bought one to use while writing Shrink Rap), and I'm not planning to buy the DSM-V.  The overall concept is good, and it's very helpful to researchers to be certain that the groups they study have some diagnostic reliability, otherwise there is no way if knowing if a certain treatment addresses a specific group of people who can reliably be classified as having a specific illness.  This isn't all bad, but I don't need 370-400 diagnosis for my work (predicted in the new DSM-V).  And Caplan makes the statement that the editor, Allen Frances, says the work is based in science but has spread it's net too far.  If you read Dr. Frances' blog, you'll note that he is quite skeptical and opposed to many of the proposed changes for DSM-V.   It's not like the psychiatrists aren't thinking hard about these diagnostic categories and the ramifications they have.  Still, I'm skeptical about how we think about these disorders, especially Bipolar Disorder. 


I agree with Caplan that psychiatrists should listen more.  Fifteen-minute med checks have made a mockery of our profession.  I also tell all of my patients to exercise, eat healthy, and look for ways to solve their problems.  But to imply that these things are the answers for the majority of people who are suffering (and often too distressed, depressed, and unmotivated, to just pull up their bootstraps,  get up and exercise and cook a healthy meal )-- is an insult.  You know, sometimes those things really do work, but if people are able to do those things, they've often tried them before seeking psychiatric opinions.  To read Caplan's piece, you'd think everyone is an idiot.  And finally, ECT: it still in use because some people find it helps.


Okay, I am ranted out.  

The DSM-5 Controversy

I've followed in bits & pieces. Sometimes for Shrink Rap, sometimes because the issues fill my email in-box, sometimes because there's no escape. Oh, and lots of the players have familiar names.

In the December 27th issue of Wired, Gary Greenberg writes a comprehensive article on the debates around the revision of the American Psychiatric Association's upcoming revision of the Diagnostic and Statistical Manual. So, "Inside the Battle to Define Mental Illness." Do read it. Here's a quote:

I recently asked a former president of the APA how he used the DSM in his daily work. He told me his secretary had just asked him for a diagnosis on a patient he’d been seeing for a couple of months so that she could bill the insurance company. “I hadn’t really formulated it,” he told me. He consulted the DSM-IV and concluded that the patient had obsessive-compulsive disorder.

“Did it change the way you treated her?” I asked, noting that he’d worked with her for quite a while without naming what she had.

“No.”

“So what would you say was the value of the diagnosis?”

“I got paid.”

As scientific understanding of the brain advances, the APA has found itself caught between paradigms, forced to revise a manual that everyone agrees needs to be fixed but with no obvious way forward. Regier says he’s hopeful that “full understanding of the underlying pathophysiology of mental disorders” will someday establish an “absolute threshold between normality and psychopathology.” Realistically, though, a new manual based entirely on neuroscience—with biomarkers for every diagnosis, grave or mild—seems decades away, and perhaps impossible to achieve at all. To account for mental suffering entirely through neuroscience is probably tantamount to explaining the brain in toto, a task to which our scientific tools may never be matched. As Frances points out, a complete elucidation of the complexities of the brain has so far proven to be an “ever-receding target.”

What the battle over DSM-5 should make clear to all of us—professional and layman alike—is that psychiatric diagnosis will probably always be laden with uncertainty, that the labels doctors give us for our suffering will forever be at least as much the product of negotiations around a conference table as investigations at a lab bench. Regier and Scully are more than willing to acknowledge this. As Scully puts it, “The DSM will always be provisional; that’s the best we can do.” Regier, for his part, says, “The DSM is not biblical. It’s not on stone tablets.” The real problem is that insurers, juries, and (yes) patients aren’t ready to accept this fact. Nor are psychiatrists ready to lose the authority they derive from seeming to possess scientific certainty about the diseases they treat. After all, the DSM didn’t save the profession, and become a best seller in the bargain, by claiming to be only provisional.

Guest Blogger Dr. Mitchell Newmark: The Relative Unimportance of Diagnosis in Psychiatry

Look, he came back! Guest blogger Mitchell Newmark, M.D. put on his armor and came to blog with us again.

The Relative Unimportance of Diagnosis in Psychiatry

As we will soon be witness to the emergence of DSM-V, the new rule book for psychiatric diagnosis, I am reminded of all the pitfalls of diagnosis in psychiatry. In other fields of medicine, diagnosis is based primarily on etiology, with objective findings, rather than on symptoms alone, as it is in psychiatry. When you go to your internist with stomach pain, there’s an endoscopy to look for ulcers, a sonogram to look for gall stones, a blood test to look for hepatitis. But in psychiatry, there is no CT scan to check for Bipolar Disorder, no blood test to assess if the patient has Schizophrenia, no spinal tap to check for Major Depression.

For the psychiatric community at large, diagnosis is important for many reasons. It helps doctors sort out patients so that clinical trials can be conducted on similar groups of patients. It enhances communication among psychiatrists when behavioral, affective and cognitive symptoms can be categorized. But for the individual patient, it is less useful. Some patients fit nicely into DSM categories, and others don’t. There are many patients who have unique combinations of symptoms across several diagnostic criteria. This leads to assigning multiple diagnoses, and confusing the treatment picture. Since diagnosis is based on symptomatology, treatment should also be based, more often than not, on symptoms, regardless of the “official diagnosis.” Latching on to a diagnosis may often limit the treatment options because medicines or psychotherapies designed to treat one disorder are considered inappropriate for treating another disorder. Flexibility is essential for coming up with the best treatment plan for an individual, especially those patients who do not fall neatly into a diagnostic box.

I am always happy to discuss diagnosis with patients, but even this can cause difficulties. For example, when I see a patient in their late teens or early twenties with protracted psychotic symptoms, not due to drug abuse or medical issues, and without the mood changes seen in depression or mania, I am asked “Is this schizophrenia?” According to the DSM, the answer is yes, but many patients recover from these episodes completely. The psychiatric answer is “this seemed like schizophrenia, but it must have been something else.” Meanwhile, the patient has had to cope with being labeled with a devastating diagnosis. I would prefer to answer, “these are the symptoms you have, so let’s treat them with the appropriate medicines. We may discover over time that you have schizophrenia, or an illness like schizophrenia, an illness that does not have a clear cut diagnosis, or this episode may resolve completely and indefinitely.” And that’s the truth.

Someday I may be able to send a patient for a PET scan and get a report back stating “Impression: Bipolar Disorder, Type !!.” By then the DSM will be a thing of the past.

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?

I Might As Well Go Home Now.

Psychiatry's getting blasted this week: we don't know what we're doing, our diagnoses are not valid or reliable, our treatments no better than placebo and we maxed out in the 1960's with imipramine. Yesterday's NYTimes Magazine article on The Upside of Depression (see my post) implies that we're derailing evolution by treating what may be an adaptive condition, and The Wall Street Journal says Psychiatry Needs Therapy ! Edwarder Shorter writes:
Psychiatry seems to have lost its way in a forest of poorly verified diagnoses and ineffectual medications. Patients who seek psychiatric help today for mood disorders stand a good chance of being diagnosed with a disease that doesn't exist and treated with a medication little more effective than a placebo.

What's a shrink to do with this? Perhaps the diagnoses we make are wrong and the meds we use are ineffective, but at the end of the day, the patients seem to get better. Maybe it's my charm (hmmm, there's a thought) or the concurrent psychotherapy, or some other non-specific factor...maybe the cognitive dissonance that you have to believe that anything you're paying a small fortune for has to be working.

So do read Shorter's article and tell us what you think.

Dr. Carlat Wants To Talk About The DSM-V

Dr. Daniel Carlat has his own psychiatry blog and he wants to talk about what's going to happen with the new Diagnostic and Statistical Manual (DSM-V). Funny they call it a statistical manual when there are no statistics (there are diagnoses!).

I'm sending you over there to join the discussion:

http://carlatpsychiatry.blogspot.com/

Diagnostic Controversy: the DSM-V in Progress...

I want to begin by saying I don't have any insider info into the process and I don't have an opinion about what's going on. Which is good, because no one asks me.

The DSM is a book that lists the guidelines for making psychiatric diagnoses. It's like a Chinese Menu--- a few symptoms from column A, a few symptoms from Column B, and voila, you've got Diagnosis X. There have been 4 versions to date, and the 5th is in the works.

It would be nice if we could run a definitive test and say, Yup, the Depression Factor is present in your blood, you've got Major Depression, single episode, and the level is 75 so it's "moderate." Or look, the left side of the amygdala is enlarged, therefore it's Panic Disorder. Or, the frontal region has increased metabolism when you burp, so you've got Paranoid Schizophrenia.

It doesn't work that way, we don't have any definitive tests and when we do tests in psychiatry as part of a diagnostic evaluation. It's to make sure the patient doesn't have a brain tumor or a stroke or thyroid dysregulation or hypoglycemia or some other medical condition (that we can see or measure) that explains the symptoms. If the brain looks anatomically normal, if the blood is normal, if there are no funny substances that explain why someone is acting or feeling either badly or weirdly, then by default, it's a psychiatric problem. Some day this may change, but right now that's it. Researchers are making progress towards finding links between psychiatric illnesses (after they are diagnosed as such) and specific genetics or brain metabolic differences, but they don't make a diagnosis and it's all pretty new.

So how are diagnostic criteria decided? A bunch of people sit in a room and decide. They talk, they look at research findings, they pool their experience, and actually I'm not all that sure (keep reading, there are some answers below). The issue of diagnostic criteria and validity is laden with emotion-- there are people who like psychiatric labels, like the drug companies. And there are people who don't like labels -- like those who don't want their sexual preferences or gender distress labeled an illness, Health insurance companies pick and choose what diagnoses they will reimburse for. So once upon a time, homosexuality was a psychiatric illness and it's not anymore.

The DSM-V work groups are in place and these peeps are talking about the next volume and what should change. There have been issues with the process of what they are doing-- the members of these groups signed a non-disclosure document, and my email (why me?) gets messages from people complaining that the process is too secretive, and other messages stating that there is a need for some confidentiality during the process, but it's open and transparent. Today's email came from the American Psychiatric Association, pointing me to a Wall Street Journal blog post about the issue, so I will guide you to that: Click Here.

Oh, and while you're clicking, Roy also posted on this issue back in November: Click Here.

Oh, and here's what the APA has to say about the how the process transpires:

The work groups began meeting in late 2007. While the 13 work groups reflect the diagnostic categories of psychiatric disorders in the previous edition DSM-IV, it is expected that those categories will evolve to better reflect new scientific understanding. With the understanding that some continuity from DSM-IV to DSM-V is desirable to maintain order in the practice of psychiatry and continuity in research studies, there has been no pre-set limitation on the nature and degree of change that work groups can recommend for DSM-V.

Each work group meets regularly, in person and on conference calls. They begin by reviewing DSM-IV’s strengths and problems, from which research questions and hypotheses are first developed and then investigated through literature reviews and analyses of existing data. They will also develop research plans, which can be further tested in DSM-V field trials involving direct data collection. In order to invite comments from the wider research, clinical, and consumer communities, the APA launched a DSM-V Prelude Web site in 2004, where these groups could submit questions, comments, and research findings to be distributed to the relevant work groups.

Based on this comprehensive review of scientific advancements, targeted research analyses, and clinical expertise, the work groups will develop draft DSM-V diagnostic criteria. A period of comment will follow, and the work groups will review submitted questions, comments, and concerns. The diagnostic criteria will be revised and the final draft of DSM-V will be submitted to the APA’s Council on Research, Assembly, and Board of Trustees for their review and approval. A release of the final, approved DSM-V is expected in May 2012.

You can read the whole APA web page about this: Click Here.

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 B...you 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:"
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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.

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The DSM-5 Debate

Christopher Lane over at the LA Times has an Opinion published in yesterday's issue exposing the debate within the APA (now spilling out) about how transparent to make the process for developing the upcoming DSM-V.

...The bone of contention: whether the next revision of America's psychiatric bible, the "Diagnostic and Statistical Manual of Mental Disorders," should be done openly and transparently so mental health professionals and the public could follow along, or whether the debates should be held in secret.

One of the psychiatrists (former editor Robert Spitzer) wanted transparency; several others, including the president of the American Psychiatric Assn. and the man charged with overseeing the revisions (Darrel Regier), held out for secrecy. Hanging in the balance is whether, four years from now, a set of questionable behaviors with names such as "Apathy Disorder," "Parental Alienation Syndrome," "Premenstrual Dysphoric Disorder," "Compulsive Buying Disorder," "Internet Addiction" and "Relational Disorder" will be considered full-fledged psychiatric illnesses.

Perhaps some think that this is another thing, like making sausage or legislation, that one doesn't want to know how it is made or what goes into it.  Let's hope not.  In fact, Robert Spitzer, who chaired the group which created the third edition of the DSM (the so-called Diagnostic & Statistical Manual contains the gold standard definitions of various mental illnesses and other conditions), sent out an open letter a few months ago calling on the APA to open up the process.  In response, the APA is now publishing Work Group reports and is planning to publish the minutes from the meetings, as well.

The DSMV is expected in 2012.