Posted by Dr. Vollmer on May 12, 2016
DSM 5 has added Non-suicidal Self Injury Disorder (NSSID) as a new diagnosis for those who cut on themselves without the intention of dying. Should I rant about this? Of course. Cutting behavior is a symptom of psychic distress, not a diagnosis, per se. The issue is what is the meaning of the cutting? Self-soothing? Attention-seeking? Feelings of helplessness in that there are few other options, or feelings of empowerment because now the person has turned passive feelings of despair into active feelings of anger? As with all symptoms, the puzzle begins, with the task of the professional to try to understand the broader context of this behavior. The act of cutting does not communicate the essence of the patient’s struggle, only that some sort of struggle is going on. This is the difference between a symptom and a diagnosis. A diagnosis is an answer and a symptom starts the questioning. As with so much of psychiatry these days, the confusion between symptom and diagnosis is disturbing. Once a diagnosis is made, questioning often stops, and treatment begins. With NSSID, this should start the inquiry, and not lead to quick labeling and a certainty of a mental illness which underlies the behavior. Mental distress does not equal mental illness. DSM 5 gets that all wrong. End of rant, at least for now.
Posted in DSM 5, Child Psychiatry | 4 Comments »
Posted by Dr. Vollmer on April 27, 2016
The powers that be in psychiatry have moved ADHD from a “disruptive disorder” to a “neurodevelopmental disorder”. Let’s pause for a moment. Not all ADHD children or adults are disruptive. Girls, mostly, and some boys, suffer from the “inattentive subtype” which means they quietly sit there and count the tiles on the ceiling, not learning because they cannot focus, but they do not cause a disruption. So, indeed, the nomenclature needed to change. Welcome ‘neurodevelopmental disorder’ and new problems arise. To the extent we understand ADHD as an immature brain, a brain which has trouble with executive functioning, sustained attention, and impulse control, then it is certainly a “neuro” disorder. On the other hand, the role of development is not clear except to say that certain children will outgrow ADHD, implying they are slow to mature, or late bloomers, as I like to tell parents. Some, however, do not outgrow it, and they suffer a lifetime with poor focus and poor executive functioning. For them it is not a developmental disorder, but a straight up disorder. If we think of brain functioning like circuits and some people lack critical circuits for functioning, then in the future, perhaps we will call ADHD a “circuit disorder”. As Russell Barkley explains, the problem with the circuit is a failure of inhibition, such that the ADHD patient is constantly vulnerable to whatever pops into his mind at that moment, leaving him or her unable to complete tasks, especially those which have little inherent interest. Further, he or she is also vulnerable to losing key items, not remembering details of a project, and failing to do daily chores, as the sudden thought, whatever that might be, overrides routine or “boring” activities. So, by my way of thinking ADHD is a brain problem, not always related to development. No one wants to think of themselves and worse yet, their children, as having a “brain problem” so I don’t think my idea would sell well, but I think it is the most efficient way to communicate our current level of understanding of this common disorder.
Posted in ADHD, DSM 5 | 7 Comments »
Posted by Dr. Vollmer on March 4, 2015
DSM 5 has expanded our notion of eating pathology to include a diagnosis of binge-eating, a behavior that almost all of us have experienced from time to time, but as with all of mental health, when the symptom is both intense and frequent, then a diagnosis is made. Along with a new diagnosis, there is now FDA approved treatment for Binge Eating Disorder, Vyvanse, a stimulant medication, typically used for ADHD. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm432543.htm
Truth be told, I, and many of my colleagues have been using stimulants to treat bingeing for over 20 years, but now we have support both from the DSM 5 and the FDA. In other words, our treatment went from “off-label” usage to “on label” usage and so for my existing patients this means more security, and for new patients, this means more awareness that there are treatments available. The closet eater can now come out of that closet. This is an exciting step forward, although the concept is simple. Drugs which suppress appetite will suppress the gratification from bingeing. Medical health improves as bodies return to a normal weight range and mental health improves as the patient feels less shame and guilt associated with binge eating.
Since I normally discuss working from the inside out, it might surprise some of my readers that here I am talking about working from the outside in. In essence, both are important. If I could not prescribe medication to help people help themselves, then I would be limited in my toolbox. Likewise, if I could not explore psychodynamic concepts with my patients, I would be even more limited. Binge Eating Disorder is an example of how if we begin to change the behavior first, then we can then proceed to work on the inner workings of the mind which led to this type of self-destructive behavior. Medications change behavior, sometimes, and when we have that tool available, with minimal side effects, then I am happy to prescribe. As with eating, it is the extremes which are a problem, not the middle ground.
Posted in DSM 5, Eating | 2 Comments »
Posted by Dr. Vollmer on October 7, 2013
Disruptive Mood Dysregulation Disorder entered DSM 5 in May, 2013. Kids that tantrum beyond some line of “normal” now have a mental disorder, which is supposed to be an improvement over calling these kids “childhood bipolar”. By my way of thinking, these kids are “higher maintenance” and they need intensive behavioral interventions in order to control their “dysregulation”. However, they do not need a mental illness label. I do not see how this diagnosis helps parents or children manage. Now, whether medication can help these children is another story. Medication may help, but that still does not mean they have a mental illness. Tylenol helps with headaches, even though the person with a headache does not have a diagnosis; they have a symptom. Once again, Psychiatry, in this case Child Psychiatry, has lost its way.
Posted in Child Psychiatry, DSM 5, Psychiatry in Transition | 4 Comments »
Posted by Dr. Vollmer on June 24, 2013
From WSJ June 16, 2013 “A Nation of Kids on Speed” by
“Last month, the American Psychiatric Association released the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders—the bible of mental health—and this latest version, known as DSM-5, outlines a new diagnostic paradigm for attention-deficit hyperactivity disorder. Symptoms of ADHD remain the same in the new edition: “overlooks details,” “has difficulty remaining focused during lengthy reading,” “often fidgets with or taps hands” and so on. The difference is that in the previous version of the manual, the first symptoms of ADHD needed to be evident by age 7 for a diagnosis to be made. In DSM-5, if the symptoms turn up anytime before age 12, the ADHD diagnosis can be made.
It’s also easier to diagnose adult ADHD. Before, adults needed to exhibit six symptoms. Now, five will do. These changes will undoubtedly fuel increased prescriptions of the drugs that doctors use to treat ADHD: stimulants such as Ritalin and Adderall.”
ADHD stabilizes in DSM 5, but the debate about it does not. This quote above, from the opinion section of the Wall Street Journal, expresses deep concern about the over-diagnosis and hence the over-treatment of kids and adults with stimulant medication. The arguments are tired and true, but also exaggerated. This is a clinical diagnosis. There are no objective findings. Physicians make a lot of money making this diagnosis and drug companies, in kind, profit from the illness. Kids are given stimulants with the potential message that they are not responsible for their own behavior. “Boys will be boys” and so why are we trying to push square pegs into round holes. In the comments, one writer expressed the notion that savvy parents help their kids get an ADHD diagnosis so the child can qualify for extended time on tests, as if extended time will necessarily help the child have a higher score. The issue of whether any child should have a timed test is yet another question in education, but that puts us on a tangent. The issue here is first, DSM 5 is not moving us forward in the ADHD world. Without an objective test, diagnosis abuse will continue. Financial incentives are there, and so abuse will happen. At the same time, for some kids, going on stimulants is like getting a pair of eye glasses. The world is simply clearer to them, so that they, and their families appreciate the monumental change in their interface with the world. My solution is simple. The better the history taking, the more likely the physician will hit the mark and the less likely there is financial incentive to over-prescribe. Quickies, or short appointments, lead to “ADHD mills” where over-diagnosis and over treatment is rampant. Physicians who take considerable time exploring the possibility of ADHD are much less likely to be vulnerable to the pressure to prescribe. A prescription can be a quick tool to rapidly get someone to leave your office. These hasty interactions is what has got to change: not the diagnosis or the treatment.
Posted in ADHD, DSM 5 | 4 Comments »
Posted by Dr. Vollmer on June 16, 2013
So, mental retardation is now intellectual disability and dementia is now a neurocognitive disorder. Old wine in new bottles. Mild Cognitive Impairment (MCI), has become mild NCD. Ditto. Why are we changing nomenclature? The cynic in me says, the ten years to produce DSM 5 had to yield change, whether it was good, bad or lateral. The more generous person in me says that it makes sense to broaden the notion that as one ages, one’s brain declines, sometimes at a slow rate, consistent with the aging process, and sometimes, tragically speaking, the brain has an accelerated decline, a phenomena we used to call dementia and now we call NCD. This accelerated decline has rumblings which perceptive patients and family members detect, and now we can label those rumblings as mild NCD. The theme of DSM 5 seems to be to create umbrellas and then deal with the details later. There is the autistic spectrum umbrella, the trauma and stressor related disorders umbrella, the obsessive compulsive umbrella and the neurocognitive decline or disorder umbrella. It reminds me of cleaning up a messy room, the first step is to make piles. There is the pile you want to give away. There is the pile to keep and the pile you are not sure what to do with. Breaking things down into piles makes the process of change less overwhelming. As such, DSM 5 feels like a temporary clean-up of psychiatry, leading the way to a more sophisticated understanding of the brain, downstream. Now, I want to take issue with the word neurocognitive. What is the difference between cognitive and neurocognitive? Is that not redundant? Sometimes cleaning up makes things messier.
Posted in Aging Brain, DSM 5, Geriatrics | 4 Comments »
Posted by Dr. Vollmer on June 15, 2013
Mental Retardation no longer exists. It has joined Asperger’s in the ‘remember when’ category. In comes intellectual disability, (ID), to remind us of Freud’s understanding of the id. A mere coincidence, I understand, but too close for my taste. In parenthesis the DSM 5 adds intellectual developmental disorder (IDD). So, the IQ test is no longer the defining feature of intellectual disability. One must consider functioning level. There are three domains of functioning: conceptual, social and practical. The conceptual domain includes skills in language, reading, writing, math, reasoning, knowledge and memory. The social domain refers to empathy, social judgment, interpersonal communication skills, the ability to make and retain friendships and similar capacities. The practical domain centers on self-management in areas such as personal care, job responsibilities, money management, recreation and organizing school and work tasks. So, what is my take? Much ado about nothing. A good assessment has always been a key feature in understanding disability. This assessment has always included understanding the impact of the disability on day-to-day life. Does the label change help parents? I do not think so. Does it help professionals approach the problem in a more comprehensive way? No. Was it important for my peers to spend countless hours debating this change to DSM 5? Maybe. They argue that this change brings the terminology in line with the World Health Organization’s International Classification of Diseases and the American Association on Intellectual and Developmental Disabilities and the US Department of Education. The name does suggest a spectrum of children, who for a variety of reasons, have developmental challenges, requiring them to have much-needed services to maximize their developmental potential. In this way, creating this umbrella does make sense.
Posted in Child Psychiatry, Child Psychotherapy, DSM 5 | 7 Comments »
Posted by Dr. Vollmer on May 13, 2013
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.
Posted in DSM 5, Media Coverage | 1 Comment »
Posted by Dr. Vollmer on May 6, 2013
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!”
Posted in DSM 5 | 6 Comments »