DSM5 and Psychiatric Research

DSM5 was never meant to be a ‘cookbook’.  Indeed the classic criticism of the DSM series is just that.  I see this increasingly with personality disorders and worse the attemp to use psychiatric as a weapon in recent political debates. I was a member of the Psychiatrists against Political Abuse of Psychiatry at a time when communists were calling all who disagreed with left wing ideology, schizophrenics. 

 My favorite clinical example of mis diagnosis was a very arrogant  oriental female elitist academic psychiatrist calling a very black regai singer manic depressive without considering of context or work.  The reggae singer’s response to the misdiagnosis was ‘at least I don’t squeak when I walk like that up tight bitch.’  

The DSM especially regarding personality disorders and traits was to be taken in their historical context. Everyone has the ‘trait’s that are described in borderline, narcissistic, ocd and paranoid or schizotypal personality disorders. The key to the diagnosis is that the over abundance of certain traits or coping mechanisms has been a problem starting in adolescence and causing disturbance in a person capacity to work, love and play.

Mental healths simply defined is the ability to work, love and play.  I was annoyed to hear a colleague, clearly envious, call a lawyer we knew ‘narcissistic’.  Of course he has narcissitic traits,  There’s healthy narcissism and unhealthy narcissism. His daily work with unhealthy narcissistic sociopaths and psychopaths required he develop in his ‘persona’ character ‘armor’ to do his job.  He was very successful in his work, was a husband with several children married to a lovely wife happy in her family and career. He had a number of past times he enjoyed with his friends and family and definitely liked to play water sports among others. 

Borderline traits are commonly bandied about because it’s common today to hear those who value and devalue and have quite shallow short term relationships and are very angry a lot of the time.  Projection and projective identification with dissociation are common in those with the personality disorder but the full personality disorder implies that the person didn’t really leave the teen age era of personality disorder, often called 13 years old going on 40.  Yet border line personality traits are common coping strategies after trauma.  Borderline personality disorder has indeed been called untreated ptsd and Borderline Personality Disorder traits are common following PTSD where the stressors are ongoing.

Abnormal coping mechanisms doesn’t mean a person is ‘bad’ anymore than abnormal sugars doesn’t mean a person is diabetic or that diabetics are necessarily diseased.

To understand psychiatric diagnosis in context it’s necessary to understand that people commonly diagnosis themselves with physician illness and their neighbor with psychiatric illness.

Further the popular media is extremely ‘off’ with regards to psychiatry tending to make a very big deal about some aspect of psychiatric research when indeed the research of psychological studies in prominent journals showing that although 97% of the major journal results are ‘statistically significant’ after a year less that 40% are valid on replication.  

Evidence based research and the Cochran’s trials are extremely open to error in psychiatry which is a combination of neurology, psychology, sociology and anthropology.  There’s mentalism and materialism competing in a marvelous soup of 3 dimensional chess proportions all being routinely deducted by  players with secondary gain issues like insurance companies, courts and drug companies .  There is further always a private and public health consideration that only infectious disease in ‘physical’ medicine seems to truly have.  The mind simply is not the brain but reductionism and pseudoscience would explain everything in eloquent terms that are simply not true for individuals though generalizable to some extent.

I’ve probably got most expertise in non compliant and resistant diagnosis in addition to addiction and trauma patients. I see anxiety and depression as the phenotyic expression and use medications that are generally non specific despite the specificity of diagnosis on occasion.  

I love Dr. Milton Erickson’s expression, when he said “we can all agree that the pot is cooked and we must get it off the fire but everyone argues about where the handle on the pot is until someone realizes they have a pot holder in their hand and pick up the pot, which is what everyone agreed needed doing.’

There is however ‘secondary gain’.  When a person isn’t getting better with the standard treatments psychiatrists ask what is the advantage of this disability. I used to diagnose malingering and have correctly diagnosed dozens of fraudulent patients. Malinger is conscious fraud whereas fictitious disorders are unconscious fraud.  I eventually got told to stop taking wheel chairs away from people who while quite able to walk were using the wheel chair as a ‘prop’ to get more money in some claim. Offended by my correct diagnosis I was eventually told that only a judge today can make a true diagnosis of malingering despite it long being a psychiatric diagnosis along with anti social personality disorder. A patient became very angry with me because I diagnosed them correctly as an antisocial personality disorder because it was going to affect their getting their restrictions reduced.

I mention this because the ‘popularity’ of a diagnosis is commonly affecting diagnosis especially when patients have the power to cost a doctor tens of thousands of dollars if they make an unpopular diagnosis . Having made hundreds of diagnosis of alocholism and addiction I was one of the most unpopular doctors and especially so when I diagnosed pedophiles and violently dangerously insane people who wanted and sometimes threatened me to make their diagnosis something that would improve them financially.

When I see a ‘popular’ psychiatrist I immediately doubt he or she has diagnosed addiction or pedophiles. Forensic psychiatrists are not commonly ‘popular’ where as general practitioners historically were. I was indeed extremely popular as a family physician and patients who didn’t like me went to my colleagues leaving me with an interesting assortment of patients who liked my ‘truthfullness’ and routinely stated they appreciated that I didn’t ‘mince words’ .  Compared to my fellow family physicians I was more ‘patient’ with patients and listened to them ad infinitum being very interested in their ‘story’. Compared to some of my colleagues being an addiction psychiatrists I’m less ‘patient’ with the ‘story’ because addiction commonly hustle and ‘work’ the story and ‘try out the story’ in an attempt to obtain another ‘enabler’.  So if a person has an addiction they will want you to believe and ‘cut them some slack’ agreeing with the disease the problem isn’t their continued use of crack and alcohol or even heroin but rather it was the parenting.  

Pscychoanalysts being paid listens and analysed addicts to the tune of millions but this ‘therapy’ simply didn’t change behavior.  Addicts and alcoholics were quite content to do anything as long as they could continue their addiction which Freud considered worse than schizophrenia.  Motivation therapy and 12 step facilitation therapies the most effective therapies in addiction focus on behavior therapy not ‘intellectualization’ which is common with addiction.

These are all context and developmental considerations in diagnosis of psychiatrists. Further in contrast to neurolgy, psychiatry is commonly one on one without the capacity to ‘triagulate’.  Triangulation is where the therapist can say, “I’m not saying you have cancer, your CTSCan says you have cancer’.

There’s simply no pictures in psychiatry that “make diagnosis’.  No lab tests’.

So indeed many diagnosis in psychiatry are culturally limited as they are comparisons against a norm which might well be antequated. I have argued that the MMPI a personality profile developed in the 50s and still popular in the legal system today is long past it’s shelf life.  Many of the personality tests preceded the social rise of LBGQ movement and the very ideas of ‘disorder’ implies an ‘order’ which might well be past. 

Further psychiatric diagnosis and treatment and research is about providing care for the ‘individual’. I did a dual speciality in community medicine and public health and psychiatry and the two fields public and individual medicine are diametrically opposed. So in psychiatry today I am acutely aware of the distinct difference between publicly funded health care diagnosis and decision and privately funded health care. In the area of addiction , the elite are offered abstinence therapy and the poor are offered ‘harm reduction therapy. I am forever making myself unpopular saying that I’ll recommend ‘harm reduction therapy’ as a first line treatment to the poor when we accept heroin treatment for judges and doctors and pilots. One therapy is cheap immediately while the other abstinence based therapy is usually more costly.  Betty Ford Treatment Centre versus a drug therapy.

Similarly the decision to diagnosis a person schizophrenic versus manic depressive or schizoaffective has profound life effects for a person and yet psychiatric diagnosis are ‘venn’ diagram. I’m frankly bored when I hear some people talk with the kind of confidence that only the truly stupid can have. I’m forever uncertain but happy to defend a ‘working diagnosis’ and as a ‘treating psychiatrist’ versus and academic or one of those who avoid or rarely see patience, live in the present and in reality. There are serious limits to what is available for most patients given that psychiatric patients are the most stigmatized and most marginalized.  We simply don’t have enough psychiatrists and psychiatrists are the most poorly paid so commonly attract the least assertive practitioners.  At one end of the psychiatric spectrum are soft psychiatrists who prefer to hang with counsellors and at the other end the ‘hard’ psychiatrists who like to work with neurosurgeons. I’ve moved up and down the spectrum also noted a wide variety between the ‘american’ based psychiatrists and the ‘British based psychiatrists’ who have trained in the ICD.  

Of course you can use DSM5 as a cook book and get away with it.  Indeed the joy of medicine is that the majority of patients respond to standard treatments.  This makes family medicine so enjoyable because historically the truly complicated cases were supposed to be the realm of specialists.  Unfortunately that model failed in where there were insufficient family physicians and insufficient specialists.  

The joy of psychiatric specialist practice is diagnosing and treating the patient who has not responded to standard treatment or been misdiagnosed or is resistant to treatment except that today there is little approach for this . The one shoe fits all approach goes with give a boy a hammer and everything is a nail.

The joy of psychiatry was assessing transference and countertransference but like ‘secondary gain’ they have gone the way side. Sadly without those psychiatry is reduced even further to being a ‘junior neurologist’ field for those who don’t really want to do the grueling research training demanded in adult neurology.