Psychiatrists Don’t Care About DSM 5?

 

http://www.nytimes.com/2013/05/12/opinion/sunday/why-the-fuss-over-the-dsm-5.html?emc=eta1

 

Sally Satel MD, writes her opinion about the upcoming release of DSM 5. Apparently former President Bill Clinton will announce the release this coming weekend in San Francisco. The book has been fourteen years in the making, and with all due respect to Dr. Satel, I think psychiatrists care a lot about this new publication, attempting to pronounce who has a mental illness. I am not sure how one can care about the mentally ill and not care about the labels which shape patient’s identity. As one of my commenters said recently, in response to my post about distinguishing ADHD from Asperger’s Disorder (now called Autism Spectrum Disorder), she did not understand herself because she was told that she had issues which made no sense to her. This confusion, brought on by clinicians, not meticulous about diagnostic classification, causes harm to patients and their families. DSM 5 is likely to cause more patients to believe they have a mental illness, when, in fact, they are struggling with issues of powerful family dynamics, causing symptoms which potentially disable them. This uptick of diagnosis brings more business to psychiatric facilities, mental health practitioners and disability offices, but it also changes the patient’s understanding of what ails them. Likewise, the promise of quick treatment, can lead patients to feel very discouraged that they are not obtaining symptom relief. It would be as if yoga promised patients flexibility, instead of promising them the journey towards deep breathing. The depth of the problem is often not captured in our diagnostic manual, and as such, patients with means, are left to seek treatment from practitioners willing to take the time and the thoughtfulness to tolerate the messiness and uncertainty of exploring an interior landscape which is varied and constantly changing. DSM 5, like DSM IV, encourages a hastiness which is destructive to training new psychiatrists, and hence destructive to patients understanding the complexity of their experience. Dr. Satel is wrong, in my opinion, that DSM 5 is a non-event to clinicians. DSM 5 dashes our hopes for a field which promotes depth and breath, rather than checklists which look at static experiences. DSM 5 is an outrage. That is the fuss.

NIMH and DSM 5: Divorce!

 

 

 

http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

DSM 5: The Retraumatization of Diagnosis

 

DSM 5 is being released at the American Psychiatric Association meetings in San Francisco in two weeks. My colleague, Robert Stolorow PhD, sums up the issue.

” Against Descartes and his legacy, the DSM, I am contending that all emotional disturbances are constituted in a context of human interrelatedness. One such traumatizing context is characterized by relentless invalidation of emotional experience, coupled with an objectification of the child as being intrinsically defective. No wonder receiving a DSM diagnosis can so often be retraumatizing!”

http://www.psychologytoday.com/blog/feeling-relating-existing/201204/deconstructing-psychiatrys-ever-expanding-bible

PMDD Walks Into DSM 5

 

PMDD, premenstrual dysphoric disorder is currently a diagnosis in the appendix of DSM IV, meaning that if a physician believes the patient has PMDD, then he/she must write Depression NOS (not otherwise specified). At the same time, there are currently drugs approved for PMDD, despite the fact that it has not achieved diagnostic status. Well, come May, 2013, after Bill Clinton speaks to the American Psychiatric Association in San Francisco, California, the DSM 5 will be announced and the criteria for mental illnesses, in the United States, at least, but probably around the world, will change, including more folks, causing a large stir about the wider scope of psychiatric disease.  DSM IV came out in 1994, making almost ten years of a classification system, which for the most part, has not matched the explosion in psychopharmacology. DSM 5 has taken a long time, mostly, as I can tell, because the debates over the diagnostic system were tense. So, it is very likely that PMDD will hit the light of day and now women who suffer from terrible irritability before their periods will merit a psychiatric diagnosis. The good news is that there will be more acceptance of the biology of mood swings, and then hopefully more acceptance of psychopharmacological interventions. The bad news is that some women, through no fault of their own, will be labeled, potentially increasing their premiums for health insurance, life insurance and disability insurance. The triad of emotional lability, irritability and anger, during the luteal, or last phase of the menstrual cycle, in about 2-5% of menstruating women, had been validated in the research over the past 20 years. This additional research, the DSM 5 committee argued, gave good reason for PMDD to be “promoted” to  a diagnosis and out of the appendix. PMDD now joins the ranks of a full blown mood disorder; it is in parallel with bipolar disorder, which also has prominent mood lability and irritability, but PMDD symptoms cease on the first or second day of menses. Plus, PMDD comes with physical symptoms of bloating and breast tenderness, making it easily distinguishable from bipolar disorder. What about heritability? You ask, knowing that most psychiatric diagnoses run in families. The heritability of PMDD ranges from 30-80% which is indeed, a wide range, but enough to merit a full diagnosis. What about treatment? PMDD is ameliorated with an SSRI (Prozac and his cousins), quickly, unlike when an SSRI is used to treat Major Depression. Also, intermittent or continuous treatment are both helpful, suggesting that a constant blood level is not necessary, but rather more serotonin in the premenstrual or late luteal phase, seems to do the trick. So, the world will change in May, 2013, the psychiatric world, that is, and hence all of us who work, love and/or experience others who suffer with negativity, irritability, and quickly shifting moods. Now, women who cycle in and out of these mind states will be legitimized on the one hand, and maybe, but hopefully not, stigmatized, on the other.

SIG-E-CAPS

This is the mnemonic for diagnosing depression, according to our current manual, DSM-IV. Five symptoms, two weeks, seriously? Let’s review. Suicidal thoughts, are these active or passive? Perhaps they are related to a traumatic event. What if they go away in three weeks, then does the person still get a diagnosis of “Major Depression”. Interest in activities, is this losing interest or diminished interest? What if the person is fatigued, as a result of anemia, and this explains the lack of interest in activities? Guilt, my favorite criteria, since so much of guilt is unconscious, are we talking about conscious guilt? If so, very few people admit to this, particularly not int he first interview. Energy, see my comment on interest. Concentration, again, see my comment on interest. Appetite, decreased I can understand is a sign of mental dis-ease, but increased appetite is often a result of increased energy expenditure. Psychomotor changes, maybe a result of fatigue, or boredom, not necessarily depression. Sleep, same as appetite, in that it is often dependent on activity level.

So, am I dismissing our current diagnostic system? Yes and no. Symptoms must be taken in context. Context is understood through building a relationship where the patient increases trust, and therefore feels more free to display the context of his/her symptoms. A rush to judgment leads to a rush to medicate, leads to a patient not understanding his/her own mind. A delay in judgment could lead to needless suffering, but I would argue that the relationship building helps the suffering, so while I obtain a thorough history, I am also helping the patient symptomatically by providing a space for thought and reflection.

I want the patient’s history to become relevant again in psychiatry. This is a major reason I have this blog. I will repeat this point until my field changes its emphasis, or until I retire. I hope for the former.

Diagnosis Dilemma

Insecurity

   William, sixty-two, wanted to know his diagnosis. “How would that change things for you?” I ask, wondering about why a psychiatric label is something that he is seeking. “I need to know I am not alone. I need to know that there are other people who suffer in the same way that I do,” he responds, tearfully and powerfully. “It sounds like you don’t trust your instincts. You know that you are suffering. You know something is not right in your head, and yet, if I were to give it a name, then you would not need to feel anxious that you are somehow imagining this condition.” I say, understanding that labels cut both ways: they help people looking for support in their condition and they hurt people who feel stigmatized by being part of the mentally ill. “Over time, I would hope that you could use your intuition to reassure yourself that something is wrong, rather than relying on outside sources to tell you that you could feel so much better.” I say, trying to explain that on top of his depressed feelings, he is also feeling insecure, or uneasy about the way he is feeling, because he has never learned to trust his intuition about himself. “That would be nice,” he says with recognition of what I am saying, “but I am not there yet,” he continues. “I am going to go to a support group. It will help me,” he says, listening to my point about his anxieties around his condition, but also saying that he is trusting his intuition in that he knows he does need reassurance so he is going to seek that out. “I am all for it,” I say, collaborating with his desire to help himself, while at the same time appreciating that it would be nice if he knew he was suffering without feeling anxious about that layer of it. The journey is just beginning.

Borderline Personality Disorder: Misogyny?

     Jolie, a mother of three, thirty-five, a full-time hospital administrator, divorced from the father of her children, breaking up from her boyfriend of two years, calls her psychiatrist on a daily basis because she is not sure if her antidepressants are helping her. The psychiatrist, Dr. K  communicates to her that she has Borderline Personality Disorder because she is not able to contain her anxiety and because she is acting in a chaotic fashion. By chaotic fashion, Dr. K explains that Jolie is “all over the place. One minute she is calm, the next minute she is crying hysterically, the next minute she is yelling at her kids.” I think about Jolie as a woman under stress and as such her emotional life is rapidly shifting.

       The diagnosis of Borderline Personality Disorder is rarely used to describe men. Dr. K and I discuss the possibility that this diagnosis may in fact be a way to demean women; a diagnosis which demonstrates that psychiatrists do not understand how a woman’s life is qualitatively different than a man’s in that the biology of female hormones combined with societal expectations of women, even in this era, makes the multiple demands on women challenging. Consequently, women are more likely to express emotions more openly, to reach out for help, which to some, could seem to be chaotic, but to others, understandable in light of the stressors. Maybe  the description of Borderline Personality Disorder is a variant of personality, but not a disorder. Perhaps it is the kind of personality which is more expressive of emotion; for the good and bad of that.

Binge Eating: A Disorder? More DSM-5 Troubles

     Binge Eating Disorder is likely to hit DSM-5. http://www.dsm5.org/ProposedRevisions/Pages/EatingDisorders.aspx. Once again, psychiatry has lost its’ way. Since when does a symptom become a diagnosis? To say that binge-eating is a disorder is like saying a headache is a disorder. A headache, like binge-eating is a symptom of underlying distress in which the physician must explore the underlying cause. Is it a brain tumor? The sinuses? Stress? Neck problems? A migraine? The symptom of the headache is the jumping off point to curiosity and exploration. Binge eating is the same thing. Is it anxiety? Is it sexual discomfort? Is it depression? Is it bad habits? By making binge eating a ”disorder” psychiatrists are discouraging the discovery of the person’s interior life.  HELP!

Hypersexuality: DSM 5, Are You Kidding?

                                                                                                                    

   As stated in this link, http://wellness.blogs.time.com/2010/02/10/dsm-5-hoarding-binge-eating-and-hypersexuality/, “hypersexual disorder would be added to the new version of the DSM as a diagnosis for people who, for a period of six months or longer, meet at least four of five criteria, including engaging in sexual fantasies and behavior as a response to depression and anxiety, or repeatedly indulging sexual desires without regard for the emotional repercussions-for themselves or others.”

   My goodness. How bad do psychiatrists have to get with diagnoses until the field is buried?

    The DSM, or diagnostic and statistic manual,  published by the American Psychiatric Association, for a profit, is used around the world by clinicians, researchers, psychiatric drug regulators, health insurance companies, pharmaceutical companies and policy makers. The manual evolved from a system which collected a census of psychiatric hospital patients, developed by the US Army, but then it was dramatically revised in 1980 to be more symptom oriented. ICD-10, the international classification of diseases, version 10, produced by the World Health Organization has a chapter on mental and behavioral disorders. The two books are not revised synchronously, so there are different codes for the same disorder.

      Given that DSM is essentially the reference book to define a mental disorder, the diagnosis of hypersexuality disorder means, to put it crudely,  that if the patient has more sex than the doctor thinks is appropriate, then the patient could be labelled mentally ill. Surely, I am joking, my critic says. Yes and no, I respond. Behavior is subjective. How can we begin to draw a line in the sand about sexuality? The critic returns. He says, well what about alcohol use? How do we decide who is an alcoholic? I see the point, however we do have objective markers; the DUI, the elevated liver function tests, the alcoholic blackout. What are the objective markers with sexuality? Pregnancy and sexually transmitted diseases  are not the same thing.

   Does Bill Clinton have hypersexuality? Does that explain Monica Lewinsky? If so, do we really want a president with a mental disorder? Forget that he lied, should his “mental disorder” be grounds for impeachment? What about John Edwards? He had sex with a woman, fathered a child, told his aid to lie on his behalf , ran for the President of the United States, all while his wife, the mother of his three living children, and one deceased child, had metastatic breast cancer. What if we say that John Edwards has hypersexuality disorder? What if he gets “treatment”? Is he now cleared to run for President again?

      What about the treatment for hypersexuality disorder? Is the goal to ensure the patient have sexuality, but not hypersexuality? Do we, as the psychiatrists, tell our patients how many times  a day, a week, a month, with one, two or three partners? If so, do we then become religious leaders in the community? What is the difference between a mental disorder and unethical behavior? If the patient has guilt, then is it a mental disorder, but if he has no guilt, then is it unethical? Does the presence of guilt imply a mental disease, or is this, in fact, a positive sign for the presence of a conscious? I am confused.

     I have seen a number of patients who have a lot of sex with a lot of partners, but I am not concerned about their sexuality, I am concerned about their relationships. I am concerned about their ego strengths, their sense of themselves, and their management of their anxiety. Sexuality is an end-result of many complicated psychological mechanisms. We psychiatrists, need to look at the underpinnings of  behavior. That is our job. To only look at the last stop on the train is to short change the wonders of the human mind. I hope we do not do that.

    Finally, I fear that hypersexuality disorder is a back door into reconstituting homosexuality as a  mental disorder. Until 1974, gays were considered mentally ill. In 1974, DSM II was amended, and homosexuality was removed from the DSM. One bemused observer of the American Psychiatric Association’s annual meeting  labeled it ”the single greatest cure in the history of psychiatry.”‘http://www.nytimes.com/2000/01/15/arts/bigotry-as-mental-illness-or-just-another-norm.html?scp=1&sq=homosexuality 

   Hypersexuality disorder is not just a step backwards, it brings psychiatry into the world of judgment, religious principles, and potential persecution. Where did the love of the brain, married to the love of the mind go? Where did the deep respect for the doctor patient relationship go? Where did protecting the vulnerable go? I fear I will no longer be able to recognize my field; the profession which seemed to me to be so personal and so respectful of individual choices. We have lost our way. I hope DSM 6 can find it again. I really hope that.