Shirah Vollmer MD

The Musings of Dr. Vollmer


Posted by Dr. Vollmer on October 15, 2012

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.

6 Responses to “SIG-E-CAPS”

  1. Jon said

    Once again, we will restate the obvious. A patent’s history is fundamentally important in psychiatry. Sadly, what is obvious to some is obscure to others. Yes, is does some up a major raison d’être for this blog. Sadly, I am not as sanguine as you that you will retire after this obvious statement will become obvious to the general psychiatric community. I hope I am wrong.

    • Shirah said

      Yes, but maybe, just maybe, my blog, along with other similar blogs, will encourage the public to give push-back to the field, thereby changing the practice of psychiatry back to a more humanitarian endeavor.

  2. Shelly said

    I appreciate your blog more and more, Shirah. You are an advocate of the careful reporting of symptoms and putting them in context of life events. One cannot diagnose depression in a patient based on one session with a psychiatrist, is that true? How would you be able to see a change in tone, energy levels, activity, reported symptoms versus general overall wellness, etc…? A patient who reports tiredness and weakness may be suffering from a thyroid disorder, anemia, or depression, or simply is of the age where a nap in the afternoon is part of their daily routine. All of it is within the context of the telling of the story, is it not?

    • Shirah said

      Yes, Shelly, you have nicely expanded on my ideas, which reach back to the pre-Prozac days of Psychiatry. Although DSM-IV came out before Prozac, the manual, combined with the revolution of psychopharmacology has made the field into a symptom-based diagnosis, instead of a narrative based diagnosis. Symptoms are binary, and hence are the first attempt to scientifically examine human suffering, but at the same time, without the story the symptoms could be misconstrued. This presents the dilemma of Psychiatry as more art than science, but hoping to be more science than art. Taking away the art makes me sad, both for the patients and the practitioners, as the value of the doctor/patient relationship erodes. Thanks, as always.

  3. mimi said

    Great commentary Shirah! So much change is going on in mental health right now – trying to incorporate accountability has sometimes seems to be rushing the diagnostic assessment and turning us into robots….

    • Yes, yes and yes!!!! I have the same feeling that artificial intelligence will one day be our competitor and how sad is that? The days of creative thinking in mental health care seem to be slipping away. I hope not.

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