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.  

Ducking Around

Ooooh, let me tell you: I love vacation.  I really love vacation.  I'm back.  It's cold here, and I spent the day unpacking and doing laundry, and getting ready to start my week.  I returned calls, went in to the office and checked my mail, emailed, postal mailed, and watched the Ducks win the Rose Bowl.  Sad, because even though we Shrink Rappers like ducks, I have my own personal Badger out in Pasadena cheering for Wisconsin, and it's a sad football day for him, I'm sure. 


Roy did a great job of holding down the blog.  Please give him a hand.  Clink was off on another one of her adventures.  For some reason, vacation is not fun for her if there isn't the possibility that she'll fall thousands of feet, get eaten by some form of wildlife, or have her life depend on properly functioning equipment while she gurgles beneath the sea.  She's the only person I know where "I had a fantastic time" is followed by an injury report.


Roy's Happy New Year duck was taken from the Havre de Grace annual New Year's Duck Drop.  From the Aegis:

It was a glorious night for ringing in a new year. Temperatures, unusually inviting for a New Year's Eve in Harford County, hovered around 43. Wind was non-existent. And many people had gathered around the Havre de Grace Middle School grounds for the annual Duck Drop and fireworks to welcome another new year.

In other stories around the web, if you're a distracted duck, you might have notice that it's hard to find Ritalin or Adderall-- perhaps another example of DEA limits allowing Big Pharma to be being overly ducky about reducing supply of the cheaper, generic medications.  From the The New York Times, do check out "A.D.H.D. Drug Shortage Has Patients Scrambling."  


And if you're a duck contemplating filing for Social Security Disability, do read Dr. Steve's post on Thought Broadcast about The Curious Psychology of "Disability."  With 41 comments on that post, I'm going to swim away from the temptation to comment myself. 

And finally, for those ducks who want to know the latest on Electronic Medical Records, check out Shrink Rap News over on CPN for "Notes from SAMHSA's EHR Summit."  If that doesn't make you want to be served up with orange sauce, then nothing will.

So I love vacation, but I did miss all the Shrink Rappin.'  Happy New Year to everyone!  

From Clink: I don't have a duck in this race, so I thought folks might enjoy a seahorse instead. He's black with white stripes and seems to be perched on top of the green moray eel's head. Yes, the eel was that close.

No significant injuries this time.  A slight jellyfish sting and lots of no-see-'ums, that's it.

More on How Lousy Psychiatrists are at Determining Prognosis

A few days ago I put up my post on the Clinical Psychiatry News website on Rethinking Bipolarity.  I talked about how we've expanded the diagnosis so that now it captures so many problems as to make the diagnosis imprecise and I talked about how we really can't predict prognosis.  In the same vein, the front page of the New York Times has an article about people with schizophrenia who do better if they keep busy with busy careers, even if they are very stressful.  In a High Profile Executive Job as Defense Against Mental Illness, Benedict Carey writes:

Now, a group of people with the diagnosis is showing researchers a previously hidden dimension of the story: how the disorder can be managed while people build full, successful lives. The continuing study — a joint project of the University of California, Los Angeles; the University of Southern California; and the Department of Veterans Affairs — follows a group of 20 people with the diagnosis, including two doctors, a lawyer and a chief executive, Ms. Myrick.


The study has already forced its authors to discard some of their assumptions about living with schizophrenia. “It’s just embarrassing,” said Dr. Stephen R. Marder, director of the psychosis section at U.C.L.A.’s Semel Institute for Neuroscience and Human Behavior, a psychiatrist with the V.A. Greater Los Angeles Healthcare System and one of the authors of the study. “For years, we as psychiatrists have been telling people with a diagnosis what to expect; we’ve been telling them who they are, how to change their lives — and it was bad information” for many people. 

It's a good article, but I have one gripe with it (...ah, for me to have only one gripe with an article by Mr. Carey is close to amazing).  He makes it sound like people with schizophrenia have chosen less stressful jobs because that's what doctors recommend.  I think some people with schizophrenia lose their motivation to work at any job because it's one symptom of the illness.  Like bipolar disorder,  schizophrenia and schizoaffective illness seem to play out differently in different individuals.  As a field, our crystal balls don't seem to work very well. 

The Special Needs Child

 

Oh, we're not kiddy shrinks, so this post is not really about children.  But I like the term, it implies that the person needs something more, that they have special-- presumably increased-- needs.  It says nothing about potential.  I use the term often, and sometimes with a bit of humor, to remind people that the playing field is not always level.  There are people who start any give race with a handicap-- a learning disability, dyslexia, major health problems, mental illnesses, horrible childhoods, addictions, -- and these set them on a slightly different course.  


Some people overcome tremendous adversity.  They function 'as if' they had no special needs.  They have stories that would let you understand if they didn't do very well in life, stories that would explain burying their heads in the sand, or crawling under a large rock.  Sometimes these special needs people are so driven to excel that they don't just hang in the race, they lead the pack, as if they had no problems as all.  They measure themselves against those without special needs and everyone forgets that they are racing with a bit of extra baggage and often very remarkable stories.  They are among the most resilient of people, and their stories are often inspirational.


Why is this a problem, or even a Shrink Rap post?  I suppose because the issues come up all the time, and they get to be problems when the special needs child gets so good at running the race "as if" they are not hindered by the weight of their problems that they come to expect nothing short of excellence. They run without the memory of their handicap and are particularly unforgiving of their lapses.  So what if one needs to rest, or if one doesn't finish the race first, or doesn't finish at all?  But even worse, their loved ones often come to expect so much that they may become critical if special needs child lags a bit here or there.


Sometimes it seems it's fine to simply say, "I have a special burden and I can't keep up right now."  


This is for Carrie who shared her remarkable narrative with me and for all the other people I know who expect so much of themselves in inspirational ways. 
And tonight, this is for Steve Jobs who gave the world so much until the very end of the fight.  

Mental Health and MLB

Roy asked me to post about this article, by Shirley Wang,
from the Wall Street Journal:
Professional Baseball Faces Loaded Problem: Mental Health

The article starts by talking about the fact that there are three Major League Baseball players on the Disabled List (the D-L) for anxiety. It goes on to talk about 'butterflies' and golfers' 'yips.' It names some professional athletes who've suffered from other mental health issues, and there is talk of pitchers who suddenly couldn't throw. The players, apparently, have access to a counselor.

What don't I like about the article? Somehow, I read it and had the flavor that these players are disabled by anxiety from the stress of their profession and the performance demands...the article ends with a psychologist being quoted as saying that anxiety is normal.

My best guess...and I don't know these players and have never examined them....is that there is more to it than stage fright, or the pressure of the biz. When you're getting paid what these guys get, I don't think they let you bow out and go on the D-L because you're job's too much and you get butterflies in front of the crowd. By the time you're on the D-L, the mental health issue is probably quite disabling, and not the normal or expectable anxiety that goes along with jitters and yips. And I can't imagine that professional sportsmen are any less vulnerable than the rest of the population to mental health issues.

Back To The Salt Mines

A Federal appeals court recently decided that paper money discriminates against the blind. They said that since blind people can't distinguish between the types of bills by feel and have to rely on others (and trust that others will be truthful), the blind are being denied access to currency and are being treated differently than sighted people.

The interesting thing about this case---besides the fact that it may make the U.S. Treasury completely redesign all paper currency---is the fact that advocacy organizations for the blind are divided about whether or not this decision is a good thing. The Council for the Blind, who apparently was a party in filing the litigation, favors redesigning the money. The National Federation for the Blind is not happy about the decision and feels that it will foster stigma against the blind by suggesting that they can't function in society as well as others.

I have to say, I was surprised about the NFB's opinion and didn't expect it, but it got me thinking about disability, discrimination, stigma and mental illness.

The Americans With Disabilities Act bans discrimination against people with physical and mental illnesses who request reasonable accomodation for their disabilities. The mentally ill person must make his or her disability known, and must be otherwise able to perform the duties and responsibilities of the job if the accomodation were made.

The down side of the ADA, as the National Federation for the Blind has pointed out in their legal case, is that mandating accomodation may increase the stigma of having a mental illness by implying that psychiatric patients need a 'leg up' compared to others and are incapable of competing on a level playing field. (Similar arguments were once advanced about anti-discrimination laws for minorities, gays and women.) Nevertheless, I think the ADA is a good thing and is necessary to protect the rights of handicapped workers. It's unrealistic to think that people with mental illness are on an equal footing with people without a diagnosis, even with their condition is completely under control.

Maybe someday psychiatric treatment will be as common and unremarkable as a regular dental visit, but until then we need to be proactive and vigilant about attempts to curb or restrict protections for those with disabitlities.

As for our paper money, I think it's due for an upgrade.
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Note from Dinah: Here's an interesting paper on The Unintended Consequences of The Americans With Disabilities Act.
Deleire (the author) makes the point that when people let their disabilities be known, they are less likely to be hired. Since many many people suffer from some psychiatric illness at some point in their lives --probably over half if you include things like anxiety and adjustment disorders. It all gets foggy on what's Reasonable Accommodation and exactly what an employer needs to do fulfill such an act for someone with a psychiatric disorder. My question might be something like, when does society encourage people to be victims, versus when are there simply people with differences. It's not just psychiatry, educators talk about such things all the time with issues of untimed SATs (college entrance tests) for those who can afford testing to officially diagnose a problem/difference--- something that seems to me a clear tilting of the scales in favor of the financially advantaged (the testing costs a ton and is not typically done in public schools for kids with reasonable grades who aren't tanking). It's hard to balance the need for fairness towards those needing some support versus the deleterious effects of having a label.
Sorry to rant on Clink's post. I'll use whatever money they give me.

Salt Mines

[posted by dinah]


I'm stealing a thought from Shiny Happy Person (and I do hope she is), the psychiatrist who blogs at Trick-cycling for Beginners.

SHP wrote:
Why, when so many of my patients are adamant that they do not have an illness, are they so keen to demand Disability Living Allowance, Incapacity Benefit, and free bus passes for those with a disability?

I've been perplexed for years about the relationship between mental illness and the ability to work. It's not that I don't think people with disabling mental illness shouldn't get benefits: I do. What I don't get is how we know when people can't work versus when they won't work, and I haven't observed a great correlation between severity of symptoms and ability to work. So, I see patients who are on disability for Depression or Bipolar Disorder who, on mental status exam, report that their mood is euthymic, their sleep and appetite normal, there are no psychotic symptoms, the medicines are working, and they are busy with a number of activities. Now, granted, these are chronic and intermittent illnesses; some of these patients have been hospitalized, all have had episodes of severe illness, but they also have periods of stability. This is not to be a comment that they should be working, just an observation.

On the flip side, some of the absolute sickest patients I have seen have worked despite their illnesses. One woman's anxiety clamped down her life such that she could tolerate no social events outside her home at all. She couldn't go to a movie or a restaurant (funny, she did have a pet but this was years ago, in the era before Emotional Support Animals, but she also had a family so if they couldn't get her out in public, would a Duck have helped??? Okay, I'm straying here, forgive me). Still, she got to work every day. And the happy ending to that story is that when SSRI's came out, her social life resumed.

The most depressed patient I have ever seen lived with constant misery, non-stop suicidal ideation, extreme guilt, constant self-criticism, and the only symptom that really responded to medication was her extreme irritability and sleeplessness. Still, this was a medical professional who repeatedly won awards and raised a family.

The most psychotic patient I have ever treated spent years in a state hospital. She is plagued by delusions and hallucinations, her symptoms dictate her every move. The symptoms here are so extreme and so unique that confidentiality concerns limit my ability to fully discuss this case, or even to distort it. In the years I've treated her, she has always had a job....well, almost, there was one brief period where she was too ill to get to work and she's left a job or two for reasons that probably haven't related to reality. A trained professional, she's at times taken positions well-beneath her abilities just to pay the bills. I would recommend she apply for disability in a flash, but it's never come up.

And finally, I once treated a man who had never worked. He'd been receiving psychiatric care since he was 10, lived with his father, never finished school despite a documented IQ in the 150 range. He struggled after the father's death, living in his dilapidated childhood home, intermittently doing chores or running errands for neighbors. He told me he didn't believe he could maintain a job at Burger King, that it might fly for a while, but he had periods where he just couldn't do anything. With decades of failures behind him, no stories of success, I believed him. The Disability folks did not, and his final appeal was denied. And so, when I see a patient who left work a few years ago, whose symptoms are now controlled with medication, who says they can't work and gets regular payments, I'm often left wondering.

Just my thoughts, no answers here, and I'm sure some of you will have great references to post, I won't steal your thunder.