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How faithful are you to the DSM?

Started By: quietcity, MD, Psychiatry/Mental Health, 10:08PM Apr 09, 2012

As a child psychiatrist, I find the DSM to be a mixed blessing. It is useful for the simple diagnoses, such as ADHD and tic disorders. But if fails partially with the autistic spectrum, and fails completely with childhood mood disorders. And why the hell is enuresis even in the DSM?

I am not blaming the authors of the DSM. I think they have taken on an impossible task. But the longer I practice, the less I rely on the DSM in formulating my assessments.

So, what do my fellow mental health professionals think of the DSM these days?
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#1 of 34, Added By: StephenBerman, MD, Neurology, 10:47PM Apr 09, 2012

I'm a neurologist, but I hope it's OK to give an opinion (I did do one year of psych residency before decided that I wanted neurology instead). I have always thought that such list and rule based diagnostic schemes were valuable as rough guidelines. But they are not laws. The same applies, for example, to the International Classification of Headache and many other "official" criteria. These are good to know about and to understand. One probably should have the reference available for use when seeing patients. But it does not always govern my diagnosis. Of course for research studies, it is very important that everyone entering patients into a study uses consistent criteria. Though one still can modify the criteria for an individual study, the "official" criteria are commonly chosen. So I think that these are extremely valuable but a good doctor needs to derive diagnostic (and therapeutic) information from many sources, not just from an official list.

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#2 of 34, Added By: raveendra, MD, Psychiatry/Mental Health, 11:52PM Apr 09, 2012

I am.

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#3 of 34, Added By: rjacobson2, MD, Psychiatry/Mental Health, 12:13AM Apr 10, 2012

78496256987248863317582-holy cow that's me

Nice to have some new folks writing.

DSM use/abuse has been an ongoing topic for years. Try looking in the archives for past discussions. Most of us feel it's a crock insofar as dx, pretty much as Steve discusses above, but we just use it to satisfy the whores (male or female)) in administration.

Regards

Jake/Behavioral Peds. So.CA.

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#4 of 34, Added By: quietcity, MD, Psychiatry/Mental Health, 1:32AM Apr 10, 2012

Reply to: #1 by StephenBerman

Interesting to hear that headaches elude specific diagnoses as well. The head is the damnedest thing, I find.

As some old comedian said, "I used to think that the brain was the most fascinating part of the body. But then again, looks whats telling me that."

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#5 of 34, Added By: An_1818256, MD, Psychiatry/Mental Health, 1:33AM Apr 10, 2012

I think DSM is a reasonable shorthand for communicating between relatively uninterested parties, and I reference it often in discussing treatment studies with families. I also use it to challenge some co-workers who use labels in lazy ways, like equating suicidal behavior with "severe depression", or PTSD based on an individual experiencing a traumatic event. It is less useful in describing what is really going on, but few people really want to know that anyway.

SR

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#6 of 34, Added By: quietcity, MD, Psychiatry/Mental Health, 1:44AM Apr 10, 2012

I am heartened by the fact that the folks working on the DSM-V are at least considering the idea that many diagnoses are not discrete, but rather, part of a spectrum. My years of working with autistic and PDD kids tells me this is exactly the case.

Every time I give someone a diagnosis, I tell them that I might diagnose them differently a year from now.

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#7 of 34, Added By: drgrcevich, MD, Psychiatry/Mental Health, 10:04AM Apr 10, 2012

"We have to pass the bill to find out what's in it."

I'd prefer to think about diagnosis as a working hypothesis that helps us organize our thoughts about what might be helpful for a given child/family. The problem is that the criteria we'll be using aren't clearly connected to an understanding of the underlying pathophysiology of what we're treating...and probably won't be for some time to come.

I worry about straying too far from the reservation in terms of the criteria (as has been the case with the epidemic of pediatric bipolar disorder) because of the concern about exposing kids needlessly to serious side effects associated with some of our medication treatments.

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#8 of 34, Added By: mrh57, MD, Neurology, 12:11PM Apr 10, 2012

Reply to: #7 by drgrcevich

There is also the side effect of labeling people, especially children who have yet to achieve a fully developed nervous system, with a diagnosis that may be premature or simply wrong.

Labels can result in a spectrum of unintended consequences in respect to schooling, work, insurance liability, social and personal development, etc.

As such, we should be extremely confident when making a DSM diagnosis before charting and documenting.

Don't forget, if you use a commercial EHR then you do not own your patients' data and chart. It is the property of the software vendor and this information is sold commercially (supposedly with the identifying information removed). So any diagnosis that you generate will add to a large cohort used by both public and commercial sources to stratify populations and determine both research and marketing strategies.

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#9 of 34, Added By: rjacobson2, MD, Psychiatry/Mental Health, 10:24PM Apr 10, 2012

78496256987248863317582-holy cow that's me

HOW FAITHFUL ARE YOU TO DSM?

I must confess/ I once fooled around with ICD-9. If I had been Catholic, though, I don't know if I would have needed to admit it in church.

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#10 of 34, Added By: ECTDOC, MD, Psychiatry/Mental Health, 11:13PM Apr 10, 2012

Shock value.

DSM is a billing manual that is all. It is efficient for that but unsuitable for anything else.

DSM use of subjectivity as the basis of diagnosis for all major psychiatric conditions (except dementia, delirium, catatonia and withdrawal) relieves psychiatrists of having to account for available evidence. However, keeping evidence as optional separates psychiatry from scientific observation.

Using verifiable observation in psychiatric evaluation does not put you in conflict with DSM because DSM ignores it.

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#11 of 34, Added By: quietcity, MD, Psychiatry/Mental Health, 1:31AM Apr 11, 2012

Reply to: #10 by ECTDOC

But most psychiatric symptoms are by their very nature subjective. Can you measure a hallucination? Can you quantify dysphoria?

That the DSM relies on subjective reports to establish diagnoses is the most honest thing it does.

And psychiatrists are hardly relieved of accounting for evidence. I spend 90 minutes gathering evidence every time I do an evaluation. The problem is, the evidence is different from patient to patient. Its as if a surgeon had to go searching from head to toe for the gall bladder in every new patient.

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#12 of 34, Added By: An_1818256, MD, Psychiatry/Mental Health, 1:50AM Apr 11, 2012

Reply to: #9 by rjacobson2

Har, har!

Shrinkrap

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#13 of 34, Added By: An_3232163, DO, Psychiatry/Mental Health, 12:44PM Apr 11, 2012

Reply to: #9 by rjacobson2

"I must confess/ I once fooled around with ICD-9. If I had been Catholic, though, I don't know if I would have needed to admit it in church."

LOL

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#14 of 34, Added By: ECTDOC, MD, Psychiatry/Mental Health, 1:06PM Apr 11, 2012

Shock value.

Reply to: #11 by quietcity

Almost every patient with a mood disorder, anxiety disorder, or psychotic disorder exhibits observable psychopathology. DSM makes using such evidence optional. THis is what is improper about it.

DSM always cuts to the lowest common denominator, subjective symptoms. By doing so DSM caters to the lowest common denominator. Subjective symptoms are precisely a matter of patient satisfaction, nothing more, nothing less. Client-patient satisfaction is of course essential in a successful practice, but it has nothing to do with science.

Extremely few psychiatrists can even see these issues because they have been so long habituated to the DSM system. You can claim honesty, but an honest lack of knowledge about the scientific method is not the same thing as scientific honesty.

Much of your 90 minute evaluations are about patient satisfaction. Evidence is independently verifiable by an observer. Taking a survey about impressions and opinions is not gathering evidence.

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#15 of 34, Added By: rjacobson2, MD, Psychiatry/Mental Health, 1:51PM Apr 11, 2012

78496256987248863317582-holy cow that's me

Reply to: #14 by ECTDOC

These comments are quite pertinent. I think at least one more point needs to be included.

While psychiatrists seemingly feel that they can, if they put their minds to it, explain behavior and feelings beyond subjectivity, they have, as far as I can ascertain, always tended to use terminology which is/was meaningful only to themselves or those who cared enough to learn them. Thus, IMO, arises the confusion and resultant antipathy.

Perhaps, if there was more effort to explain things in more concrete and functional terms and descriptors, patients and other professionals would be able to feel comfortable with our analyses.

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#16 of 34, Added By: quietcity, MD, Psychiatry/Mental Health, 3:13PM Apr 11, 2012

Reply to: #14 by ECTDOC

ECTDOC, you say: "Almost every patient with a mood disorder, anxiety disorder, or psychotic disorder exhibits observable psychopathology. DSM makes using such evidence optional. THis is what is improper about it."

Observable by whom? And observed using which measures? Rating scales are based on DSM criteria, after all. If I reject the DSM, which criteria do I use instead?

Answer these questions, and you will revolutionize psychiatry.

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#17 of 34, Added By: mrh57, MD, Neurology, 3:14PM Apr 11, 2012

Reply to: #15 by rjacobson2

Just because you have MD, DO, or PhD behind your name, the suffix doesn't protect you from the same bias, prejudices, and mores that affect the rest of our society.

Until his recent death I was unaware of the Mike Wallace's 1967 report (based on then current medical opinion) that pegged homosexuality as a mental illness. This is a great example how medical thinking was influenced not by facts but by the bias' of society.

When we don't understand things we use either generalized terms that attempt to describe the phenomena or the last name of the person who first took notice of the situation and described it (frequently a syndrome instead of a disease)

After we have been able to find evidence that leads to generally accepted mechanisms, identify both the etiology and subsequent pathology, and develop mechanisms to measure and quantify it, the condition becomes "real" and "concrete"

Don't forget that in Osler's first two textbooks of IM asthma was considered a psychiatric disease of woman...then PFT testing was developed, immunological dysfunction was identified, beta receptors and agonists came to light and asthma became a disease.

Migraine was often considered a psychiatric disease of woman until a feline model of cortical spreading depression was developed, cytokines were found in cerebral venous drainage, 5HT1D receptors and agonists were discovered, and migraine became a disease.

Phantom limb pain was thought to be a psychiatric disorder. People were even institutionalized because they couldn't get over mourning for a lost/amputated limb. Then we discovered peripheral nerve neuromas, pathological changes within the dorsal root ganglion, cerebral cortical reorganization of both the sensory cortex and motor cortex (plasticity of the homunculus) and phantom limb pain became a disease.

The secrets of the CNS; the brain, self awareness, consciousness, and thought processes continues to elude us and we continue to be plagued with bias, prejudices, and mores that affect how medical colleagues approach the field of psychiatry.

It is ironic that psychiatry residents must do several months of a neurology rotation but neurology residents are not required, and typically shun, psychiatry rotations. Some of my most memorable encounters occurred doing 4 months of psychiatry split between a locked inpatient unit and emergency department psychiatry. Considering that serious mental illness is around 4.5% of the population and that depression, anxiety, and personality disorders are more common than sources of fresh and potable water I am amazed that both physicians and society continue to dismiss the contribution of psychiatry.

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#18 of 34, Added By: An_1818256, MD, Psychiatry/Mental Health, 3:20PM Apr 11, 2012

Reply to: #16 by quietcity

"Answer these questions, and you will revolutionize psychiatry."

Wait for it......

As in...

http://www.urbandictionary.com/define.php?term=wait%20for%20it

Shrinkrap

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#19 of 34, Added By: raveendra, MD, Psychiatry/Mental Health, 10:48PM Apr 11, 2012

Reply to: #17 by mrh57

where have u been all these years? you are my kind of physician. It takes a lot to impress me. I like your level headedness, reasoning, objectivity, competency. I will treat u as my friend but we don`t have to agree with each other all the time.

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#20 of 34, Added By: An_1818256, MD, Psychiatry/Mental Health, 11:00PM Apr 11, 2012

Be afraid?

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#21 of 34, Added By: mrh57, MD, Neurology, 11:22PM Apr 11, 2012

Reply to: #19 by raveendra

Thank you...I feel sort of stupid...

I have been registered with Medscape for at least a decade but rarely ever perused the site aside for the occasional article and CME. It was only recently that I became aware of the Connect feature.

Wow, it's fairly addictive and there is a lot that I've learned from other peoples comments.

It has also been nice to share the experiences that have allowed us to be successful in our approach to medicine and to continue the tradition of the curb side consult with peers from a wide range of locales.

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#22 of 34, Added By: ECTDOC, MD, Psychiatry/Mental Health, 1:14PM Apr 12, 2012

Shock value.

Reply to: #16 by quietcity

Rest assured that I had several articles about such things in very widely read publications for psychiatrists, and that not one person wrote to dispute.

Rating scales are just as subjective as DSM.

As I said DSM is about billing. This is what you need to do to make a living. What criteria do you use instead--for what purpose?

In my scholarly publications and books I described objective diagnosis as related to the main topic of the publication or book. Published reviews of my books wrote that my methods of diagnosis differ from the mainstream use of DSM. They did not discuss any specifics, such as gaping holes and subjectivity in DSM. End of story and so much for the revolution.

Of course the bureaucracy of psychiatry resists change in its methods. If there is to be a change psychiatrists themselves will not bring it about. DSM5 is really just a way of preserving DSM4.

I published answers to these questions and the status is quo, thank you.

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#23 of 34, Added By: An_1818256, MD, Psychiatry/Mental Health, 1:17PM Apr 12, 2012

/scene.

Shrinkrap

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#24 of 34, Added By: quietcity, MD, Psychiatry/Mental Health, 1:29PM Apr 12, 2012

Reply to: #22 by ECTDOC

The DSM was not developed as a billing manual. That it has evolved into one is the fault of the insurance industry. Of course, things have come sadly full circle, as clinicians now see the DSM as a billing manual. So it goes.

So, tell me: how does one objectively diagnosis a psychiatric condition? Has there been any scientific validation of your technique? Is this technique something that anyone can use?

Care to offer a bibliography of your publications?

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#25 of 34, Added By: ECTDOC, MD, Psychiatry/Mental Health, 11:28PM Apr 12, 2012

Shock value.

Reply to: #24 by quietcity

Objective diagnosis uses observable signs. I use it. Some colleagues I used to work with use it. I tried to teach residents about it, but my blind studies of these residents' skills showed that they failed to achieve good skills in it. They were not dull, some were fairly astute, and I believe that the teaching from other faculty distracted them and confused them. I reported their lack of ability to assess observable signs in a new research report at an APA meeting.

Learning these skills requires serious practice and focus, and is not related to the skills ordinarily taught during psychiatry residency. Just reading about it is not enough. I have tried corresponding with others through these posts to teach them, but I think this was a waste of my time. I am far more successful teaching patients than teaching other psychiatrists.

Scientific validation? Why have a higher standard for objective diagnosis than for subjective diagnosis. Let's start with this: Is there scientific validation for illness diagnosed with subjective criteria? Of course there can not be. There is no validation for DSM diagnoses of mood disorders, anxiety disorders, or psychotic disorders. There is only pretend validation.

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#26 of 34, Added By: An_1818256, MD, Psychiatry/Mental Health, 11:35PM Apr 12, 2012

Reply to: #25 by ECTDOC

"I have tried corresponding with others through these posts to teach them, but I think this was a waste of my time. I am far more successful teaching patients than teaching other psychiatrists. "

Do you have any objective measure of this?

still Shrinkrap

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#27 of 34, Added By: quietcity, MD, Psychiatry/Mental Health, 12:07AM Apr 13, 2012

Reply to: #25 by ECTDOC

Dr. Etcetera, you are committing the logical fallacy of begging the question. That is, you are using syllogistic circular logic. That is, you are full of it.

Give me a real example of a psychiatric diagnosis you can discern using only observable signs. And in doing so, I will assume that you will make no use of input from the patient, as such input would be all yucky and subjective.

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#28 of 34, Added By: mrh57, MD, Neurology, 1:41AM Apr 13, 2012

Reply to: #27 by quietcity

If I may jump in I've been a visitor to some remote observatories and I have met some astronomers that are the poster children for schizoid personality disorders. I've also been to NYC and have seen people that are either untreated schizophrenics or very talented actors/impersonators. Neither of these diagnoses require very much direct interaction but these people are fascinating to observe.

But then I am not a psychiatrist, nor do I routinely use the DSM, and I may be a victim of my own delusional thinking.

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#29 of 34, Added By: An_1818256, MD, Psychiatry/Mental Health, 3:06AM Apr 13, 2012

Reply to: #28 by mrh57

Wanted to say that I especially "liked" your last post;#17.

I often say psychiatric disorders are only psychiatric disorders until there are tests and imaging studies, and understanding of pathophysiology. Once they are "diseases", some other specialty is fine with owning it. Till then, it's up to "us".

BTW, this includes Medscape "connect" addiction.

Shrinkrap

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#30 of 34, Added By: quietcity, MD, Psychiatry/Mental Health, 4:43PM Apr 13, 2012

Reply to: #28 by mrh57

mrh57, thanks for the thoughtful comments. I can think of a few psychiatric diagnoses that do not necessarily need direct subjective input from the patient. Autism is one, and I suppose selective mutism is another.

But the overall point I am making is that psychiatric diagnosing and prognosticating relies heavily on face to face interaction with our patients, and the gathering of subjective information. It will be a long time before we have any useful diagnostic biomarkers.

And besides, a psychiatrist is not just a doctor of the brain, but also a doctor of the soul. Psychiatric illness is not simply a case of mis-wired neurons or chemical imbalance. Psychiatric illness is also a factor of how the patient perceives himself, and his relation to others.

There ain't no X-ray or blood test that is going to tell us all that. And even if there were such tests, it would still be easier and cheaper just to ask the patient.

A final point: the ill people you see on the streets in NYC (or any other city) may be people with addictions, or untreated bipolar disorder, or untreated medical conditions.

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#31 of 34, Added By: ECTDOC, MD, Psychiatry/Mental Health, 4:58PM Apr 13, 2012

Shock value.

Reply to: #27 by quietcity

Your statements are unnecessarily discourteous. I was never discourteous to you. End of conversation.

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#32 of 34, Added By: mrh57, MD, Neurology, 5:22PM Apr 13, 2012

Reply to: #30 by quietcity

As social animals there is nothing more interesting athan having face to face interactions with our patients.

We have all been told that the, "history is everything." If the day ever comes where we don't have to talk and communicate back and forth with our patients, because the tricorder makes the diagnosis, it will be time to start retiring or to start a new career path.

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#33 of 34, Added By: quietcity, MD, Psychiatry/Mental Health, 6:22PM Apr 13, 2012

Reply to: #31 by ECTDOC

EtcDoc, my comments are necessarily pointed. You are making remarkably grand claims about new ways of diagnosing psychiatric illness, but you offer absolutely no data to back up your claims. You expect me to believe you just because you say so.

I call this quackery, and I have no patience for it. This type of posturing is what gives psychiatry a bad name, as TF will all too gleefully remind us. Any second now....

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#34 of 34, Added By: raveendra, MD, Psychiatry/Mental Health, 12:09AM Apr 14, 2012

"call this quackery, and I have no patience for it. This type of posturing is what gives psychiatry a bad name, as TF will all too gleefully remind us. Any second now.... "

Mama Mia. Trouble brewing here!!!

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