DSMV

Hoorah!
I just received my new American Psychiatric Assocation, Diagnostic and Statistical Manual of Mental Disorders - DSM5 - 5th edition.  It's been a long awaited highly controversial text. I've just done the overview and really it's looking overall very good. The devil's in the details but first glance this is a great book.  A whole lot of terrific work.  Well done! 
July3, 2013
I got to read some more of DSM5
PTSD criteria has been broadened over all but has some more specific subcategories. I think it is more in line with the way it has been used clinically though I can see problems arising. Overall it's clear that some serious thinking has gone into this area of trauma related illness and it's well reflected in the clinical thinking inherrent in the changes since DSMIV. This is an area I work alot with and can see myself enjoying using the DSM5 without any overt concerns.
Bipolar Disorder II - the Bipolar Disorder I has remained much the same and hasn't had any controversy attached to it over the years.  Mania is a pretty drastic presentation so it's not one that gets overly misdiagnosed.  Bipolar II however has had serious flaws in diagnostic thinking lacking any real 'exclusion' criteria surrounding the term hypomania.  The idea that 'hypomania is irritability' is where the major crux is. If you're 'irritable' for 4 days now you can be diagnosed with a 'major' mental illness which can reflect on you 'freedom', 'work', 'income' and reputation.  However, a psychiatrist can safely prescribe a wide variety of medications that are likely to improve your mood.  Bipolar II and Bipolar Spectrum Disorders has been where drug companies have had their recent greatest influence as well reported in the book Unhinged, among other sources. That said there's really clear evidence that while the DSM folk might have still been overly influenced by the industry in this regard, there's an attempt to tighten up the diagnosis in specific areas. Therefore I'd say that the prescription pad psychiatrist won't be changed by this but a more concerned clinician with some diagnostic conscience will find this a better diagnosis than was available previously. 
Cyclothymia is well detailed in DSMV.
Substance Abuse - this was a very controversial area and it leaves a lot to be desired.  But it's far from as bad as some of us Addiction Psychiatry/Addiction Medicine sort thought.  It's only about 10years outdated in conceptualization but it's not 50 years out of date or on another planet like some feared.  It's really not changed much from DSMIV on first sight . Again the details will count.  There's some improvement in language. What I do like is that substance use depression is under depression. There was obviously a need for the Substance Use Disorder like this to be categorized under the headings and this has been done with Substance Use Psychotic disorder listed in the grouping for
Schizophrenia and Psychotic Disorders.  When all the chameleon colours of substance abuse disorders was listed separately novice practitioners and especially counsellors routinely misdiagnosed substance abuse psychosis and mood disorder and anxiety disorders because they were not listed under psychosis, mood or anxiety.  This is an improvement I think. The category of substance abuse itself in he desk reference is just fine, broad and specific as needed. Consistent with ICD9and 10 and not much different from DSMIV and probably easier to use clinically in the desk reference because the presentations of this category are often messy and overlapping. The specificity of the previous DSMIV was fairly academic and there's evidence this is more user friendly
The specific substance abuse areas are well documented too
Obviously I'll have more to say about this category when I go through the big book in detail but really it's not as crazy as people feared. I think everyone can work with it but appreciate that Addiction folk feel short changed as the opportunity for DSM5 to reflect the scientific advances in the field, as evidence by MRI, PET, blood urine, end organ damage etc and all the advanced knowleded now available in genetics and neurochemistry isn't clearly evidenced but that's possibly not the job of DSMV. 
Schizophrenia and Psychosis - I think this section is pretty damn good.  It's really well described schizophrenia, brief psychotic episodes, schizophreniform illness, schizoaffective disorder and substance induced psychosis. Can't see anything with first overview I'd disagree with.
 Personality Disorders- I'm really pleased that  the original Jungian categories of essentially odd, extrovert and introvert have been maintained.  There's been major advances in this field which are represented by more dimentionality but frankly I was concerned with clinically having to learn a whole new way of thinking about personality even if it's more scientific. I can see doctors working in this field being very disappointed but again I'm kind of happy it's not going to change the whole Axis II thinking radically. I suspect others that don't work in my areas of interest will like the conservative elements that have influenced DSM5 because while I individually as an addiction psychiatrist who works with trauma have specific concerns I'm pleased when I see that others broad areas have retained their overall basis.  DSM5 is a major undertaiking as much political as scientific, just getting all the doctors with competing agendas to sit at the table.
And this is looking overall like a really worthwhile undertaking.  An amazing contribution like a new encyclopedia Britanica.
The Neurocognitive Domains is a great section that really is an advance and reflects much of the new knowledge in traumatic and degenerative brain changes. Well done DSM5
The Sexual Dysfunction section in DSMIV was really well established and there's more of the same good thinking and work in this DSM5.
Eating disorders seems good too. No surprises, nothing off the wall. Just what we're concerned about clinically.
The Dissociative disorders were highly controversy but seem to be here in a very usable form. 
Somatic Sympton and related disorders seems on first glance to be better conceptualized overall and a very useful set of categories laid out the way clinicians think./
The sleep disorders are well established also with clear definitions and criteria. 

I''m going to say that again with first and second go round at this book, the DSM5 is a truly great work overall with naturally some areas of controversy. It's been a long time coming and a whole lot of very dedicated folk have done an overall amazing job at categorizing mental illness in a way that is clearly going to be useful to clinicians.  Having seen some 10 thousand psychiatric cases over a quarter century or so I think this new DSM5 is going to serve me well.  I'm looking forward to to the courses and controversy and discussions that will flow from this book and result in development of a likely even better DSMV.  It's only too bad that DSMV doesn't have a 'spiritual psychiatry" section.  A V code would have been nice. That would be asking the APA to raise the bar higher than it's usually used too though. Other V codes have been improved on in a major way with the addition of 'suspected and confirmed categories" in the case of 'abuse' which previously was 'assumed true' when indeed it's turned out that there's a real place in the world for the legal term 'alleged' and it's apparent that psychiatric diagnosis are demanding some 'boundaries' in this regard. 

There's a lot of little category changes and additions which will need specific review but again overall it's really an admirable work.

 I know DSMIII is a whole other animal than this DSMV. I'm looking at the advances in my life time a bit like the Star Trek series of enterprises over the centuries of that show and this is only in a matter of decades. The advances made in science and the clinical progression is truly amazing. 

The American Psychiatric Association deserves to be highly applauded for this major and extraordinary contribution to our collective medical knowledge.  Thank you to all involved in the production of DSM5. 

Hoarding

The DSM V study group for Anxiety Disorders is proposing  including hoarding with the Obsessive Compulsive disorders in  the new American Psychiatric Association diagnostic manual due to come out in the next year or decade, depending on hoarding controversies.  I actually have treated several hoarders but in retrospect am surprised that it has not come to my attention more.  When i did home visits i encountered it commonly but didn't register it as a disease as much as an adaptation of aging and poverty.
More recent cases have definitely fit a pattern as the patients were wealthy and their hoarding was causing them personal distress and social distress. In one case the person's residence was considered a fire hazard by the fire department and they were ordered to address the problem that had accumulated over decades. in another case the pateint insisted on wanting to unload the clutter but found it impossible to let go of anything.
There's no agreed definition as yet.  The terms for hoarding include, hoarding, compulsive hoarding, pathological hoarding, and disposophobia. The suggestion is that the collection of things of various values is outside the normal and somehow interferes with basic activities and mobility.
It should be noted that there's a potential implicit social discrimination in this definition because obviously the rich can aquire several homes beyond the normal and yet with all that space to store loot in it would clearly not interfere with their mobility or community safety.  Indeed if the very rich were truly concerned they could buy a fire department to put up beside their houses of hoarding.  This might well be what museums and galleries are, a window dressing for a more nefarious disorder, a whole area of discussion best left for the political sociologists..
The first cases of obvious hoarding i saw were 'downsized' elderly patients I did home visits on. Because their finances were such they'd had to move from large houses to small apartmentsl  One man was living in a few feet of his apartment with the rest of it serving as storage space.  The difference between most hoarders and 'collectors' is that 'collectors' have a better appreciation of 'value' and their collections have potential financial value.  One patient had an extraordinary number of comic books which caused his family to joke and make fun of him until the day he sold just one of them for thousands.  This does suggest that the term 'hoarding' needs to clearly separate itself from 'collecting'. Further, one man's treasure is another man's junk.
Somewhat tragically one of my patients thought his 'stash' was potentially valuable but due to his schizophrenia and head injury his assessment of value was grossly impaired. I asked him what he thought the 'stuff' he had was 'worth' and what it would have to be worth before he sold it.  His assessments were grossly off and grossly inflated. Yet I've a friend now who has kept furniture from an old house in a storage locker sufficiently long that she might well have put a downpayment on a new house with the accumulated rent that the storage locker has cost her to store her depreciating furniture.
There is a false sense in the general public that 'stuff' has intrinsic value without realization that the buyer and seller of second hand goods must be able to store them, have them viewed and connect buyer and seller in some way with alot of work establishing attractive prices. Ebay and Craig's List and Kikiji have all turned what might once have been called 'junk' into good transferable 'cash'.  This then is another consideration in the world of 'hoarding'.
I have personally the problem of replacing old stuff with new and taking an inordinate amount of time getting the old out.  I can think of several pairs of shoes due for disposal but i don't want to throw them in the dustbin and keep meaning to drop them off at the special bin for recycling clothes for the poor.  The constraints of time and the priorities of my life make acquisition more important than disposal.  When I trip over the old I'm more likely to raise the priority to a higher level which is a trait that most hoarders lack. They seem to develop a 'blind eye' to the increasing abnormality of their environment  in a way 'addicts' fail to see themselves as others do.
This has caused hoarding to overlap somewhat with shopaholism, one of the addictive diseases.  Compulsive buying though in research is showing up to be a distinctive disorder, possibly part of a spectrum, but definitely distinct from the inability to dispose of goods.  Hence the term 'disposophobia suggesting that true hoarders suffer less from acquring than a failure to let go.
There's been an attempt to differentiate hoarders in a way like the traditional a, b,c classification of personality disorders.  Cluster A hoarders then are more bizarre with schizophreniform hoarding and explanations.  These are those people who have food items in their refridgerators for years yet ignore this eat them and become sick because they can't accept that certain things have lost their value.  Alternatively cluster b extroverted personalities are more likely to hoard things with a future plan and wheeling dealing strategy. Cluster C being introverts and more overtly fearful with the ocd classification thrown in here would hoard because of fears of 'not having'.  B 's intend to get rich while c's would fear the future and believe they would need the 'loot' in the event of a catastrophe.
Certainly there's a lot of 'anxiety associated with hoarding.
One hoarder I saw that comes to mind began hoarding in grief though..  This may well be a way things such as this start. A major involuntary loss in life is dealt with by holding on to what one can.  I know  that one person simply could not let go of many things that had been associated with a previous loved one till they had worked through their grief.  Perhaps this will be considered a special subset or if clinicians do detailed enough histories they would find this more common as a starting point.  As yet no one knows simply because the studies haven't been done.
For hoarding to be a disorder it must be a concern to the individual or society.  It's important to note that my concern for my neighbour's collection of vintage cars has nothing to do with my concern for him. I have frank envy and this might well express itself as my wanting to help relieve him of his obvious burden and perhaps even assist "treating' his disease by taking that particularly nice porche off his hands.
In contrast my patient was simply ashamed and embarassed by her own inability to deal with collected clutter.  She had taken to closing rooms and not having people over. It was affecting her life dramatically.
My own treament in the few cases i've been priviledged to be of assistance has begun with an SSRI medication such as prozac or cipralex.  There are a variety of these and as yet there's not a clear picture of which is best.  With my OCD patients prozac certainly was the best but zoloft seemed to work best as a first line treatment for the ptsd patietns who were considered part of the overall 'anxiety' classification.  So I've used an SSRI to begin with and found that in the few cases I've treated the dosage necessary was higher rather than lower than the normal dosage.
Naturally I've provided some insight, cognitive behavioural and supportive psychotherapy. Motivation therapy approaches have helped. Planning and setting a date and keeping a journal have also been useful.
In addition I've encouraged the patient to go through the clutter with a friend or family member.  The fact is, I personally can't let go of old t shirts, each with a memory attached but a friend could well make the task very easy by noting that many of the ones I work on my boat or motorcycle with are long over due for turning to rags.
"It's a Wonderful Wife" is a company locally where a woman recognised that men and women often needed a person to do things like clean clutter which was the role of the 'traditional wife'.  I've given patients the card of this organization and  another whose name i have at the office. These people have for a reasonable fee done wonders to 'cure' the immediate problem.  The fire department was definitely satisfied with their assistance in one particular case.  Given the established use of 'anxiety buddies' well established for use in plane phobias and agaraphobia it's not surprising that this approach is so successful. However, the disorder is a relapsing, waning and recurring one and my patients had a tendency to get right back into the old patterns so medication and therapy had to be continued for at least a year .
To date MRI studies can distinquish hoarders with OCD from non hoarders with OCD. It appears that hoarders have the greatest activity in decision making areas of the brain suggesting impairment and difficulties in those areas.
At present the research is 'early' but it's a particularly interesting area considering the 1 and 99% placards at Occupy Wall Street  Perhaps in the near future the  Goldman Sachs and Humbug Scrooge will be treated for their disorders with brain surgery rather than dream therapy.

Psychosomatic Medicine and Psychiatry

All medicine and surgery is "psychosomatic".  Yet politics and law and people's attitudes remain in the dark ages or simply there are alot more stupid people than intelligent ones.  No one wants to be told "it's all in your heads".
Yet that's essentially what I do, in a way, daily. I say that 'illness' is in your mind. I'm a hypnotist. I've hypnotized people so they forgot their illness and I 've hypnotized people so they had illness they didn't. I've hypnotized people and their pain has gone and I've hypnotized people and they have experienced pain.
I assisted a neurosurgeon and as we probed different parts of a patients brain they experienced pain, the absence of pain, ticks and the absence of ticks, smells and the absenece of smells.
Phantom limb syndrome is the experience of the limb that is missing.
Now face it, without a mind, and especially without a brain, experience is radically diminished.
Schizophrenia is a disese of the mind without any clearly reproducible evidence of 'body' damage.  In contrast I have patients who have existing brain tumors whose thoughts and behaviours are no different than any others.  A big wad of cancer tissue doesn't change their identity but one day a person with schizophrenia  wakes up and believes some one has stolen their identity and the identity of their familes.  One disease is bodily profound yet makes little waves in the patients life while an innapparent switch is changed in anothers and their whole life is relatively lost.
The head bone is connected to the toe bone and vice versa.
Further, psychiatrists and somatic doctors have an uneasy relationship.  The somatic doctors are really happy to pass off all the unknown mechanism disorders to the psychiatrists. After they have depleted all their millions and millions of dollars worth of tests they project their own gross inadequacy by denouncing the patient as 'invalid' in their strictly physical sense and hence 'psycho'.
Ideally as a psychiatrist and medical specialist I'd feel respected if I was consulted early on obvious connundrums but increasingly I'm stigmatized as badly as my patients.  No one wants to deal with the mentally ill or their caregivers.  We're too 'unknown'.
As a result we're desperately as psychiatrists trying to establish a physical basis for the illness of our patients to validate ourselves and them before our colleagues and society who would rather us all  be put back in asylums than allowed to walk among 'regular' people.  Indeed the stupidest of the lot, the ignorant bullies, deny any problem, deny mental illness, close asylums and put everyone who doesn't agree with them in jails.  Jails are simple places for simple minds.  Many a genius has known such confines.
Yet every time we prove a mental illness has a physical cause up jumps a physical doctor who wants to steal it from the realm of psychiatry.  Hypothryroidism was one of the last psychiatric conditions to be taken by the Endocrinologists. The Rheumatologists nabbed fibromyalgia , what we called 'somatic depression', when it seemed  there were consistent trigger points and some reason to believe it wasn't just a 'factitious disorder'.
Yet the fact is, all medicine began in psychiatry. As psychiatrists we're the oldest aspect of physicians and as physician psychiatrists were the original  witch doctors and healers. We dealt with the 'possessed' and the 'evil' and we were there when we found that so much of what was once thought to be 'malingering' and a product of 'masturbation' per se was found instead to be a virus or bacteria or a brain injury.  Neurologists are the greatest theives among our colleagues, happy to steal anything that isn't nailed to the floor of psychiatry. They even have 'behavioural neurologists' who are neuropsychiatrists by a different name.
So should we continue to lose our patients to these 'press gangs' of regular doctors or point out that most of the illness they treat with great sanctification is a product of the deviant thoughts and behaivour of their patients.  Heart disease patients are commonly alcoholics, workaholics or food aholics.
As an addiction psychiatrist I'm fully aware that most of the disease seen by family physicians is really in my territory.
It's no surprise there's a shortage of psychiatrists.  We've more psychiatrists than ever before but our colleagues have recognised that while they were pilfering our individual cases their whole fields of medicine have slipped under the umbrella of psychiatry.  Family physicians are desperately playing catch up to learn psychiatry in order to treat diabetes and asthma with any degree of success.
Everything is biopsychosocial and even the surgeon must admit his work is in the realm of the psychosomatic.
Psychiatric interventions follow diagnosis and psychiatrists have long been the end resort of diagnosis so have well documented skills in this domain. We're also therapists, psychopharmacologists and interventionists.
I just regret they disarmed me.  I liked that when I began in surgery I carried a knife and did so in family practice as well.  In psychiatry they gave me a choice, if you don't give up your knife we won't give you the keys.
I went with the keys.  Still some days I miss the knife.

Mood Stabilizers

The first mood stabilizer was Lithium Carbonate. This was the treatment of choice for mood swings and remains the treatment of choice for Bipolar I, manic depressive disorder. The principle concern in use of Lithium is that it can cause kidney disease. To this end one checks Creatine and Glomerular Filtration rate before starting the medication and then again at 3 months and thereafter every 6 to 12 months.  Lithium can also cause thyroid disorder and this also needs to be assess before starting treatment and thereafter at 3 months and then every 6 to 12 months.  Lithium levels are established with safety and efficacy being in the .5 to 1.5 range depending on laboratory normals.  I give these figures here to say that if one is using the lithium predominantly for prevention then the dosage should be established where the lithium level is around .5 however if a person is acutely manic and a risk to self and others the lithium level will be established at around 1.5.  This said Lithium can also be used in the low dose range 300 to 600 mg to augment other mood disorder treatments.
Tegretol or Carbamezapine was the next medication found to be a mood stabilizer. This was used as the second line of choice in Bipolar I, manic depressive disorder.  It's also an antiseizure medication and specific therapy for temporal lobe epilepsy. Clinically I have seen it's benefit with anger management as well.  Bipolar II is a tenuated form of Bipolar I and was previously called 'cyclothymic' or 'dysthymic' disorders.  It can benefit from the use of carbamezapine especially if the 'irritability' component is outright anger.  That said it's use in Asian populations has to be considered in terms of cost/benefit because of the risk for a subset with HLA-B-1502 Allele developing fatal dematitis.  If use is considered in asian population then test for HLA-B-1502 is indicated first.  Aplastic anemia and agranulocytosis blood disorders are a risk so cbc with special attention to wbc is indicated.  The CBC should be taken before starting mediation. There are alot of serious reactions possible including hepatitis, pancreatitis, suicidality, water intoxication and arrythmias.  Therefore CBC, wbc, liver enzymes and EKG are to be considered before starting and when the patient is on the medication especially with increasing dosage.
Valproic Acid was the mood stabilizer most promoted for Bipolar II and so called 'rapid cycling' disorders.  The difficulty with these variants of bipolar is there is a lack of specificity and interrater reliability. Clinically it is also common for mood swings and complaints of them to occur in patients with addiction. When the clinician commonly fails to take an intensive alcohol and drug history or the patient is not forthcoming, the patient is at risk for having liver disease missed. There are been cases of sudden death with valproic in patients with liver disease.  Liver screening is indicated. Adverse reactions noted in Eppocrates include coma, encephalopathy, aplastic anemia in addition to the concerns that can occur with Carbamezapine.  My tendency is to not use valproic acid in the drug and alcohol populations which I treat where liver disease must be considered as most likely. That said I have seen other patients whose lives have been much benefitted from the use of valproic acid.
It should further be considered that the dosages used in psychiatric treatment are often far less than these medications have been used at for seizure disorders for which carbamezapine and valproic acid were first used for.
Gabapentin and Topamax (topiramate) are other mood stabilizers which have benefit in psychiatric disorders.  Topamax must be considered carefully as it can be associated with kidney disease and it can cause reversible with stopping the med unusual localized anaesthesias.  Topamax is often appreciated as it is also associated with weight loss.
Lamotrigine is the latest of the mood stabilizer medications and has been shown to be very beneficial in some cases.  It tends not to be a first choice but has been very robust in its efficacy further it has benefit in augmenting other therapies. It has a side effect profile similiar to valproic acid with sudden death and aseptic meningitis.  I can't say I've heard of any of these complications and my patients have benefitted as greatly from this medication as from the apparently safer carbamezapine, gabapentin and topiramate.
Oddly Dilantin, another anti seizure medication doesn't appear to have any benefit in treating mood disorders.
Clonazepam, the long acting diazepam (valium)  and lorazepam the short acting anxiety medication are interestingly 'anti seizure medications.  Given this it's not surprising that other anti seizure medications have benefit in anxiety disorder, irritability disorders and the bipolar disorders.
Increasingly atypical antipsychotic medications such as olanzepine, rispiridol, seroquel (quitiapine) and the newer abilify and zeldox have become mainstays of use for 'mood stabilization.'
There is always ongoing conflict with pharmaceutical companies and the regulating bodies around this issue of 'off label' and 'on label' usage. These latter drugs were developed at 'anti schizophrenia' drugs but as schizophrenia commonly has a major anxiety component with some schizophrenias overlapping with mood disorders clinicians naturally use these medications with complex cases and find them beneficial.  Medicine is art and science and psychiatry is very much so. The pharmaceutical companies develop medications that are profoundly beneficial for patients and the government regulatory bodies do their best to regulate their usage to reduce the risk to the population.  The politics of this are often difficult for patients who don't understand that very often a safe and very helpful medication for them specifically is politically and legally suddenly in question because of the means whereby it came to market.  Ironically if a pharmaceutical medication of proven benefit says that its good for anxiety and depression where it's only got 'on label' promotion for depression the company can be sued for millions.  I say ironically because the so called 'health food" "alternative medicines" can make no end of unproven and mostly false claims without any legal consequences.  Further much of the information that is being given to patients by pharmacists is not relevant to them as the doctor chooses a medication and dosage which is specific and considered in the light of their clinical experience.  Because of problems of the courts and the FDA more often than not the side effects given for medications are 'medical disclaimers'.  One case is a million risk is shown beside a one in 100 risk side effect without any explanation given to patients.