Saturday, May 2, 2009

DSMIV - Saviour or Devil

DSMIV – Saviour or Devil

-william hay

DSMIV – Diagnostic and Statistical Manual of Psychiatry

ICD – International Classification of Disease.

There are a group of men and women who decide on the meaning of everyday words in any language. The book “The Professor and the Mad Man” is a delightful story about a couple of the contributors to the making of the Oxford English Dictionary.

In Medicine we have a dictionary as well. One part of that dictionary is a series of terms which refer to what we doctors agree is the name for a collection of symptoms and signs which we call a disorder or disease. Symptons refer to the Subjective complaints of the patient whereas Signs refers to the Objective observations of the doctor. Together these are listed and grouped in specific ways to created entities which we call “diagnosis”. This is the “naming” of a thing.

In psychiatry there remains a great deal of disagreement over the very “naming” of a thing. This was indeed true for physical medicine only a hundred years ago. Today we take for granted that the vast majority of doctors agree that a thing is called “pneumonia” and that a particular pneumonia should be given “penicillin” because it is caused by an entity called a “bacteria”.

In psychiatry we sometimes envy the physical doctors because their world is so much simpler as a result of the agreement in most fields around the “naming” of the thing. This is the level of “Diagnosis”. However in the area of treatment there is still considerable controversy about the “Therapeutics” which are best used.

In Psychiatry the forefathers of present day DSM got together and tried to establish a consensus of “names” which the collection of practitioners could agree on. Increasingly today there is beginning and just beginning to be the kind of “consensus” that exists in most of physical medicine. DSMIV is the latest manual of diagnosis.

This is not even a “disease” classification but rather a “descriptive” “disorder” classification. It’s a bit like a group of people who speak a common sounding dialect so we chose to call that “german” in an attempt to see if these people have other matters in common.

The confusion arises when these “Disorder” classifications are treated as “Diseases”. In classical terms the DSM is really a “dictionary” of “mental illness” but increasingly people have “jumped the gun” so to speak and, otherwise intelligent psychiatrists, among them claimed that the DSMIV diagnosis of “disorders” are indeed “diseases” in the traditional medical sense.

The idea of a disease involves in medicine a higher standard of “consensus” and a predictable course and development and understanding of pathology and treatment than what exists in most of DSM IV. Hence the name “disorder”.

Schizophrenia as a term is really simply “prolonged” psychosis. And Psychosis as a term is really what might otherwise be called a kind of “fever” of the brain.

This in no way denigrates the tremendous work of DSM and especially DSMIV. But it is this recognition of it’s limits and indeed it’s “humble” origins that make it such a tremendous asset to the field. Where charlatans make it something that it isn’t is when the problems begin.

This occurs when a person says for interest the patient has a “clinical depression as diagnosed by DSMIV and therefore must be on this specific medication”. DSMIV and the word “clinical” in this case have been brought in to “bolster” up the observation of “depression” but neither “dictates” the therapeutics. Indeed today there’s probably greater disagreement around therapeutics than ever before despite the increasing agreement about naming the thing. In the past since no one shared a common dictionary it was simply thought that the difference in “therapeutics” reflected the difference in the entity being treated.

However with the advent of DSM there is now consensus around the entity being treated so that the difference of practitioners therapeutics and schools of theory are becoming more readily apparent. The focus increasingly today in on the comparison of outcomes to different therapeutic strategies once there is agreement on the entity being treated. This is indeed what occurred in physical medicine fifty years earlier.

While psychiatrists may be at the cutting edge in many areas of their practice and approach to illness when it comes to functioning as a medical subspeciality they’re very much in the area of “catch up” with DSM being a tool for that purpose.

With that understood it’s important also to note that everyone can have a DSMIV diagnosis. In contrast to physical medicine where there is such a thing as a “well baby” clinic and the idea of “good health” there is no such agreement on what a well person is from a psychological or emotional or psychiatric position. There is simply no consensus on “wellness” in psychiatry. While we may collectively agree on what a “depression” is and recognize that an individual is dysfunctional in his or her family, in the work place and as a member of the community we can’t likewise say with any certainty what a truly “well” person is.

Furthermore, DSM developed in the time of “insured” medicine and for psychiatrists to see people they required a “name”. Insurance companies and governments were then and commonly remain now “unwilling” to pay for psychiatric diagnosis and treatment. The “stigma” against mental illness is the same stigma that faced “physical illness” at the turn of last century. Many insurance companies and government personnel along with large segments of the community blame people with mental illness the same way as once people were blamed with physical illness. Hence DSM did not include an Axis I ‘Psychiatrically healthy person” because quite simply they wouldn’t get paid. Yet when a person with a perfectly fine heart and chest comes to the physical doctor to complain of chest pain, the physical doctor gets paid to tell them they’re having a “panic attack” and that the condition is a psychiatric condition which requires treatment by a psychiatrist. At this point the insurance company in the 21th century proceeds to refuse to pay for their treatment because in the lowest form of abdicating from cost and further insurance company gouging of the individual they deny payment for health care while falsely claiming to be in large print a “medical” or “health care” insurance policy while in fine print saying they will not treat patients for their mental illness.

DSMIV consequently is a dictionary of “inclusion”. It includes all categories. Axis V which is the Global Assessment of Functioning Scale indeed might give a 95% for overall functioning and it’s assumed that the person is well from a psychiatric point of view but they will still receive a diagnosis of mental illness because to be paid “seeing a psychiatrist” presumes mental illness even if the psychiatrist says “no mental illness” which is the best he can say because psychiatry has not agreed on what is “wellness” from a psychiatric point of view.

DSM attempts to remove the “value laden” elements from psychiatry that persist in religion and philosophy. In physical medicine our doctor and a doctor of the enemy would both agree that a soldier is “physically well” and both doctors might say in unison that the young man is “fit” and “a fine specimen of youthful physical health”. Unfortunately because of the lingering politico-religio –legal elements of psychiatry that are routinely demonstrated by the diagnosis for cash positions of “forensic” psychiatry our soldier would be seen as “psychiatrically fit” whereas the soldier of the enemy would be seen as being “schizophrenic” or suffering “group delusions” or indeed just simply an “anti social personality” disorder. There is no “Geneva convention” for psychiatry.

Hence DSM IV has many elements of politics and religion and philosophy and culture, morality and ethics clinging to the naming of things but continues to try to achieve a consensus based on a broad spectrum of observation. And it has achieved a great deal in the process. It’s a monumental undertaking that has propelled psychiatry out of the middle ages at least into perhaps modernity.

Unfortunately it is increasingly misused by the American Psychiatric Association and various other players in the field of it’s endeavour. This is not in the area of “naming” so much as it is in the area of “therapeutics” but increasingly the “name” is held to define the therapeutics and many names in DSM overlap with other names.

The whole area of mood disorder for instance is the most “inclusive” of the DSMIV. For this reason it’s the easiest to apply and requires the least training and skill in the “naming” process. Indeed because the names in the mood disorder group are either “up” – mania or “down” – depression or “up and down” rapid cycling, an idiot can make the diagnosis and call themselves a psychiatrist.

Unfortunately for a diagnosis in general medicine to have any “validity” the diagnosis must be “exclusive” and “inclusive”. The terms used are “specific” and “sensitive”. The diagnosis must include those with the specific condition and exclude those without the condition.

Mood disorder diagnosis are driven by “industry”. Last week I heard a psychiatrist who had sold her soul and probably her ass to the drug company she worked for claim 75% of women suffered from bipolar mood disorder.

Now she may be right. I’m a male and I’m not about to disagree with her on her bad hair day but what concerned me is how no one else was willing to step up to the plate to question this.

Being a physician first and a psychiatrist second I wondered how far a “hip prosthesis” company would go with orthopods if the company orthopedic surgeon said 75% of walking people need a hip replacement. Yet this is exactly the same that the psychiatrist was saying and given the cost of the lifelong treatment for “bipolar disorder” this person was saying that 75% of women in the country should be on a dangerous medication for life because their “moodiness” was pathological. The cost to each of these women to achieve “normalcy” according to this female psychiatrist naturally working for this drug company would be at least 1 million dollars in their life because the monthly cost of the medication being hawked was $500 a month. Indeed this woman was recommending that most women should give up their apartment or car and take her product so her stock in the company would increase.

The only tragedy was that this woman presented herself as a University Department head and was making her claims under the guise of being a psychiatrist.

Certainly the average person sees a person who is on tv acting like a woman doctor and recommending a particular brand of sanitary pads recognizes that they themselves might not even use that pad but are indeed getting paid for marketing it.

The tragedy is the mentally ill commonly have difficulty with trust, reality perception and issues of judgement and insight. They don’t realize that no they can not trust that psychiatrist. The psychiatrist may be working for an individual drug company. Most psychiatrists use drugs and recommend drugs but are not working for a drug company. University psychiatrists used to be independent of direct “kick backs” and “corruption” by “unnatural conflicts of interests” but its been increasingly documented that psychiatry departments and psychiatrists have been most ready to roll over and work for a “third party” interest other than their patient.

In contrast to physical medicine the diagnosis of a patient is not uncommonly for the patient and for society. In general medicine this is most uncommon. Public health doctors are separated from the physical doctors and most often the physical doctor is the direct “advocate” of the patient. With managed care and other insurance incursions into the doctor patient relationship this is rapidly decreasing but it was indeed the norm when a person went to a general practitioner with a broken leg and was referred to a orthopedic surgeon for that leg to be set.

In contrast psychiatrists have always had a major function in working for the state and public health considerations have always been a part of their services since the psychiatrist can decide whether a person is mentally ill and requiring hospitalization against their will. In physical medicine unless you’re infectious you’re unlikely to be forced into the hospital against your will. The average doctor doesn’t do this thing as a regular matter and may never in their training encounter such a situation. Yet all psychiatrists do this. It is a routine in psychiatry.

The diagnosis is what is significant in these issues. If a person is diagnosed Schizophrenic or Manic Depressive it’s implied that they are delusional and need to be on medication and indeed that they can be a danger to themselves or others on occasion. The “label” here “dictates” the “treatment’.

Therefore if a psychiatrist has an idea about what “treatment” he wants to give then the “label” he chooses from the “choices” in DSM will dictate the patients treatment.

Mood disorder diagnosis are simply the easiest and quickest to record. One can’t be “wrong” or even perhaps proved “wrong” if one says some one is “depressed”. Most people have periods of depression and as elation is now defined as “hypomania” or “irritability “ is called “hypomania” indeed it follows that 75% of women have a mood disorder and need to take the company pill and should spend their money at the doctors rather than on a new house. Indeed if they disagree they risk being forced to “comply’ through imposed hospitalization.

Where this is problematic for others is that a “Mood Disorder” diagnosis is non specific. Patients with Anxiety Disorder, Substance Abuse and Alcoholism, Post Traumatic Stress Disorder and Impulse Dyscontrol and Personality Disorders and Schizophrenia all almost invariably have a Mood Disorder.

The treatment unfortunately for Mood Disorder doesn’t treat substance abuse but may make it worse. The treatment for Mood Disorder is wholly inadequate for the treatment of personality disorder. The diagnosis of “mood disorder” implies an inherent weakness within the individual and further may deprive them of a more specific compensatable diagnosis such as adjustment disorder or Post Traumatic Stress Disorder which implies a problem outside the individual as opposed to solely ‘blaming the victim’.

Increasingly the patient today sees a psychiatrist who says they have Depression and take this pill when what the patient wants to say is “I’m depressed because my father is sexually abusing my daughter” but the psychiatrist can’t hear that because to do so would take “time” and “time” is money and further “cultural awareness” requires an understanding of “what causes depression” whereas a pharmacological definition of “depression “ is simply that it is a “drug deficient” condition.

DSMIV remains an excellent text and indeed it’s been called the Bible of psychiatry. Unfortunately as the Bible has and continues to be used to cause war and harm people despite it’s wholly different message DSMIV is today being used to cause disease and main people. That is no reflection on the book but rather reflects on a society and the politics and culture of the society.

DSMIV is one of my Bibles. And I pray that I use it for the patients benefit because I know that I can use it for harm as I can use it for good and regardless of the institution touting it it remains the best dictionary of disease and mental illness we have today.

I just hope that more people become educated about mental illness so they recognize what has already been recognized in physical illness. It was only 50 years ago that women were being told that they had to have hysterectomies en mass. It was then recognized that the greatest risk factor for a woman in regards to hysterectomy was the proximity of a surgeon. In physical medicine there are checks and balances on the diagnosis of conditions which require “surgery’. There are increasingly responsible approaches to medication treatments as demonstrated in “evidence based” practices.

I can only hope that the diagnosis and therapeutics in psychiatry “catch up”. I would hope that they would surpass the rest of medicine. If you are schizophrenic or have Manic Depressive Bipolar disorder you need to know this and you can be helped by having the correct label. However you can be equally harmed by not getting the correct label in the same way as a physical doctor who says you have “gastritis” may well be right. But if he fails to diagnosis the dissecting aortic aneurysm you will die. In psychiatry no one “misses” a “mood disorder” but increasingly the diagnosis of schizophrenia, post traumatic stress disorders, substance abuse, impulse disorder and much more are being missed.

That’s the tragedy with DSMIV. It’s not being used as the makers intended but rather it’s being used as the Bible was used. The psychiatrist like the old time preacher “proof texted”. See, he’d say it’s says here in the Old Testament this one thing and based on that a whole religion would follow. Even in theology today the ministers are asked to study the whole of the Bible and not lift parts out of context. It’s most unfortunate that company doctors and others with conflicts of interests are not being asked to go back to school when they fail to give people thorough psychiatric examinations but jump to a “prescription pad diagnosis”.

Used properly DSMIV is a tremendous benefit to the patient. Used as it so commonly used today it’s a danger and a menace.

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