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Archive for the ‘diagnosis’ Category

There’s been a lot of noise lately about how awful the new version of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association is going to be. Virtually none of this drive-by criticism appears to be the least bit informed as to the goals of the DSM-V, much less the process by which it has been developed.

A recent critical article: Why Many Mental Health Professionals Are Ditching the DSM-V ‘Bible’. There are SO many problems with this article, yet most will completely elude detection by readers.

1. The title asserts that “many” MHPs (Mental Health Professionals) are abandoning the DSM-V. Absolutely NO evidence is given for this assertion. A cheap shot, nothing more.

2. The title refers to the DSM as a “Bible”, which it is not. The Bible is considered to be a revelatory document (by believers) or a historical document (by non-believer scholars). The DSM is neither. It’s a data driven, clinically validated, periodically updated classification scheme, and nothing more. That’s all it’s designed to be.

3. “major players in the mental health community say the book needs more research”. Who are these “major players”? The NIMH is mentioned, but that’s now old news, and not immediately relevant, anyway (see #4 below). Unnamed academics from Columbia and Rutgers are also referenced – complaining about the DMS’s lack of epidemiological perspective, and insufficient consideration of ancillary causal factors. As usual, these non-clinician critics want the DSM to be the kind of research review it never was intended to be. It’s for working clinicians, not researchers. It USES research, in several ways, but is NOT a research report, review, or even summary. Once again we see non-clinicians simply failing to understand what we in clinical mental health are actually doing in our work.

4. NIMH director Thomas Insel is paraphrased (correctly, I think) as saying the DSM lacks validity because it classifies disorders solely by their symptoms. Pray tell, what is the alternative? The DSM, in recent iterations, derived from a desire to diagnose not according to theory (for which, by definition, there was little or no formal research support) but according to actual clinical presentation – yes, symptoms. WHAT ELSE DO WE HAVE? This isn’t a mistake, it’s a NECESSITY. We’re playing the only game we actually CAN play, at this point in the evolution of our knowledge of mental illness.

Insel’s project is a research strategy, for an agency with a very strong commitment to basic (i.e., physical science and medical) research. But don’t expect it to answer all questions; it simply can’t

There is a vast amount of research – from studies of morphology in biology to the famed “Minnesota twin studies” in psychology – which supports the idea that what one sees in the real world is about 50% derived from genetic factors and 50% derived from environmental factors. The conceit that any study of genetics+environment will allow us to account for the spectrum of depressive disorders, anxiety disorders, and most particularly trauma disorders is either phenomenally ill-informed or gratuitously over-optimistic. The further notion that the results of such a effort will properly be considered “medical” presupposes that psychology can be reduced to physiology, at the least. Yeah, and while you’re at it, let’s reduce computer programming to mere electronics. This is sort of “reductionist” logical error one is cautioned about as an undergraduate. Such decomposition of a higher order field to one or more lower order fields has never, to my best knowledge, happened – outside of the realm of theory, not is it ever going to.

For how many decades has the search been unfolding for a “gene for alcoholism”? And the results: still looking…

“Further evidence and an approximate estimate of heritability – crudely speaking how genetic a condition is – can be derived from twin studies that yield figures of 50% for males and 25% for females…” (Ball, D. (2004). “Genetic approaches to alcohol dependence”, The British Journal of Psychiatry
185: 449-451 doi: 10.1192/bjp.185.6.449)

What this should make clear is that “medical” approaches to such things will ever only get us part of the way to our goal. The rest of what it will take has to do with behavior, learning, and a causal model that will contain a number of non-physical factors. And alcoholism is EASY, compared to anxiety, depression, or trauma disorders.

It is fundamentally misguided to think that psychology can be reduced to physiology or medicine. Yet, if awareness of this thinking error is not much in the minds of the general public, it is also significantly lacking in the minds of too many mental health professionals. Insufficient awareness of this error is at the heart of much criticism of professional clinical psychology by non-clinicians outside of the field. They just don’t get it. Clinical work is NOT research any more than research is theory. Different areas of thoughtful activity – different goals – different processes – different rules – different outcomes. So shall it always be.

I appreciate that several rather subtle considerations are touched upon in my remarks above, of necessity. This is ALL about explanatory and prediction strategies, and THAT topic isn’t seriously taken up by most students until graduate school. If this were an easy topic, it’d be covered in high school.

Biology is still actively arguing about species delineation and classification (a fascinating topic, by the way). It’s hardly surprising that we are doing the same in the nosology of mental illness. It’s part of the process by which science improves itself. We’re NOT in trouble; we’re just doing our job.

[based on a 2013.05.14 post to the G+ Trauma and dissociation: education and advocacy community]

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[NOTE: This post is a work-in-progress, posted here to make it available at the earliest opportunity to a number of interested individuals. I will soon be adding more content, sources, and references. Meanwhile, the core of my argument is decently laid out, and will be, I should hope, informative. ~t.c.]

For years I have watched the psychiatric community’s increasing interest in bipolar disorder[1] (BD). Once a mysterious,  troubling, and untreatable phenomenon, it has become the ideal psychiatric illness: it’s apparently organic in origin, it responds, often well, to a variety of medications, and appropriate diagnosis and treatment often leads to highly significant restoration of functionality for afflicted individuals.

This affliction, major in its impact on an individual’s ability to live and work successfully and with the appearance of normalcy, shows us just how powerful and useful modern psychiatry has become.

During approximately the same time, one of the most perplexing and disruptive of the personality disorders[2] has also been receiving increasing attention, although not from psychiatry, which has had little to offer it: borderline personality disorder[3] (BPD). In 1993, clinical psychologist Marsha Linehan published documentation of her research validated treatment program for BPD. A first, it has since been joined by other validated approaches.

There is, however, a back-story to all this – several of them, in fact. I will focus on two: the transformation of psychiatry into a role with diminished significance in the mental illness treatment community, and one probable consequence of this: the very real problem of misdiagnosis of both bipolar disorder and borderline personality disorder.

Back-story #1: Psychiatry, once dominant in mental illness treatment, becomes second-fiddle

It is a little hard to believe, in our time, that in the recent past the application of psychology to problems of mental illness was all but non-existent. If one had a “mental illness”, and there was not an obvious and treatable organic cause, one got psychotherapy (if it could be afforded) from a psychiatrist. But there were three problems with this services delivery model, all contributing to the demotion of psychiatry as the primary source of research and treatment services in mental health:

Problem 1: Psychiatrists were (and still are) necessarily expensive. The training of a psychiatrist was and is long, arduous, and expensive: after attaining an MD or equivalent, one did a multi-year residence in psychiatry, which itself involved training in two only casually related fields: psycho-pharmacology and psychotherapy. When finished, there were training expenses to be recouped, and ostensibly valuable services to be offered, at a price which would be expected to reflect their supposed value.

Problem 2: Psychiatric psychotherapy was not grounded in science… In the 1940s, 50s, and 60s, psycho-pharmacology didn’t amount to much, which more or less eliminated one of the hurdles would-be psychiatrists had to cross. Psychotherapy itself was dominated by the psychoanalytic, psychodynamic, Jungian, and other largely European and Freudian-derivative theoretical orientations, which were all busy distinguishing themselves as bastions of theory, not science. Psychiatry of this time presents the curious picture of individuals who have received some of the best scientific training available anywhere embracing a body of learning rooted almost solely in anecdote and experience with clinical populations who representativeness of the larger population of individuals needing professional attention was unknown and of no apparent interest. Psychiatry was functioning more like religion, or philosophy, than anything resembling an empirical science.

Problem 3: …Consequently, psychiatry got modest results, at best, and with only a few disorders. However, this problem was about to addressed by a different breed of service provider. Experimental psychologists, working in the fields of learning and cognition, were busy distinguishing themselves as bastions of science, with the result that well-grounded systems-models of brain function were developed which could be fruitfully applied to multiple species, including the human one. Applications of these models began to get results where before there had been little – with prison populations, addicts, conduct-disordered adolescents, back-ward chronically mentally ill individuals, and even the ordinary “worried-well”.

This was all accomplished with new, previously unseen levels of efficiency in delivery of treatment services, and without the burden of the opaque, obfuscated psycho-analytic, -dynamic, or -whatever theory, which was still being thrust at psychiatric residents in the medical schools and hospitals as the supposed best thinking that was available in the field.

To put it as clearly as possible: in outpatient settings, and at times in inpatient ones as well, psychologists were clearly getting better results than classical psychiatry, more quickly, and at a service-delivery-hourly-cost significantly below that necessarily charged by psychiatrists. Psychiatry was in trouble, and there was no obvious solution to the threat posed by emergent clinical applications of research validated models of mental function emerging from experimental and cognitive psychology.

A national response: modern clinical psychology is born. These results psychologists were getting got noticed. After World War II ended, it was apparent to the US Government that thousands of returned servicemen and women needed help that couldn’t be provided either by physicians (because their dis-ease was not fundamentally organic), or psychiatrists (because there weren’t enough of them, and they weren’t basically affordable anyway). Clinical psychology DID exist, but the cohort of professionals was breathtakingly small.

So, the US Government did what governments do best: it initiated a system-wide response to a system-wide need, called a conference of psychology department chairmen (as they were, then), in Boulder, Colorado, in 1949, and basically told them that funds would be made available to them for the development of clinical psychology programs in their institutions. Modern clinical psychology was born, as a social institution, in the space of a few days. The solution to the post-WWII mental health services scarcity problem, if not instantly created, was nevertheless launched.

It takes a few years to train a service provider in clinical psychology, but they do not need to have a PhD to be as effective as a one, and even with one they are out the door and working far sooner than any psychiatrist could be. In addition, they are far more price-accessible to most people in need. Finally, due to the superiority of their training (being science-based, not theory-based), they are often more effective with more problems.

Clinical psychology has always been based on experimental psychology, and has never been the property of psychiatry. Because psychiatry never brought into its psychotherapy practices the scientific methods of general allopathic medicine, the psychotherapy it offered was surpassed by therapy which was based on scientific research – that of the experimental psychology community. Whether they wanted to or not, psychiatrists now played second fiddle to clinical psychology in the mental health professional community.

Backstory #2: The resurrection of psychiatry, as physician to the mentally ill, paves the way to diagnostic myopia and misdirection

Fortunately for psychiatry, there were two saving trends on the rise in the sixties: the ascendancy of biochemical biology and modern neuroscience[12], and  the emergence of truly effective psychotropic medications. These trends completely revived the notion of an effective organic approach to mental illness, an approach which Freud and his associates and students had abandoned simply because they had so very little to work with.

When new drugs made it possible to push the chronically mentally ill out of hospitals and into the community, the need for effective medical management of this population was created. Now, both psychiatrists and the drug companies, as well as politicians seeking to minimize tax dollars sunk into management of the chronically mentally ill, had a shared  interest in seeing psychiatry flourish. Chronic mental illness was largely seen as deriving from organic causes (even though the research supporting this was skimpy at best, in most cases), and thus accessible to medical management – if the drugs could be found. Soon, many of them were, and “big pharma” made sure the psychiatric community knew about them.

It has subsequently become clear that the big pharmaceutical companies have become masters of capturing the attention the professional psychiatric community. They provide the most accessible information about psychotropic medications (the Physicians’ Desk Reference), and are “..the source for most clinical research” funding in psychiatry[4]. As psychiatry had come too often to dance to the tune of big pharma, there have been problems[10]:

  • The childhood bipolar disorder research and diagnosis scandal[5];
  • Suppression of unfavorable drug research results[6];
  • Obfuscation of authorship of pharmaceutical research reports[11];
  • Complicity with price gouging by the pharmaceutical industry[7];
  • Continuing controversy about the freedom of the leaders of the psychiatric community to do their own thinking[8].

It goes without saying that all of these issues were and are vigorously disputed[9], with big pharma often leading the way.

What cannot go without saying is this: in spite of problems associated with the transformation of modern psychiatry into what it is today:

  1. The level of expertise in the profession, relative to management and treatment of organically based mental illness is at an all-time high. What modern psychiatry does best is not done better, or even as well, by any other profession.
  2. The treatment efficacy of the profession, relative to organic disorders, while still not what is desired by all of us, is also at an all-time high, and at its best is simply exceptional. Today, psychiatry can change and  save lives in ways never before seen. We should all be grateful for this.

A consequence of the fall and rise of modern psychiatry: misdiagnosis of bipolar disorder and borderline personality disorder

This much, at least, BD and BPD have in common: both are under-diagnosed, in some circumstances, and over-diagnosed in others. This may seem odd, but there is substantial evidence of this, and there are multiple factors contributing to the problem[13].

[Note: I must stop here, today, but will return at my earliest opportunity to complete this. See my last footnote for some of the sources I’ll be using.]

NOTES

1. For reliable and well-written professional summaries of the bipolar disorder diagnosis, please see Bipolar Disorders and Bipolar Affective Disorder.

2. For reliable and well-written professional summaries of personality disorders as a class of problem, please see Personality Disorders (at the Merck Manual website), Personality Disorders (at the Medscape website), and  (at the NIMH website).

3. For reliable and well-written professional summaries of borderline personality disorder, please see Borderline personality (at the Merck Manual website), and Borderline Personality Disorder (at the Medscape website), and Borderline Personality Disorder (at the NIMH website).

4. See NIMH RDoC vs DSM, paragraph three.

5. The center of the controversy has been Harvard psychiatrist Joseph Biederman, how has been extremely active both in promoting the concept of childhood bipolar disorder and its diagnosis, and in receiving vast amounts of money from the pharmaceutical industry. In an effort to be fair, let me just say that this raises questions about self-promotion, intellectual independence, and trust, which do not benefit psychiatry, Harvard, or Dr. Bierderman.

6. A book could be (and several have been) written on this subject, the incidents are so numerous. Here’s one especially disturbing incident, involving apparent suppression of research indicating that certain types of antidepressants are not safe for children. Additional coverage of this problem is available in Drug Companies & Doctors: A Story of Corruption.

7. Again, where do I start? Well, here one interesting place – a lengthy, carefully sourced article by Marcia Angell is a Senior Lecturer in Social Medicine at Harvard Medical School and former Editor in Chief of The New England Journal of Medicine: The Truth About the Drug Companies. Here’s an interesting response to her article.

8. See Conflicts of Interest Plague the Next International Manual of Mental Disorders, Experts Argue.

9. Here’s one noteworthy exchange, between Marcia Angell (see note 7, above) and several individuals of note.

10. …and that’s an understatement. See Drug Companies & Doctors: A Story of Corruption for much more on this.

11. See Authorship Rules for Medical Journals Flouted by Pharma Industry, Experts Say, and Ghostwriting Revisited: New Perspectives but Few Solutions in Sight.

12. The decade from 1990 to 1999 was declared by President George H. W. Bush to be the “Decade of the Brain”. This was both a call for increased effort in, and focus on, neuroscience research, and a recognition of the immense promise of the field, given its current status. For more on this, see Project on Decade of the Brain.

13. Partial list of sources to be used:

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Instead of some light summer reading, I offer you some heavy spring reading – it can’t really wait until summer.

The coming new edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (expected to be published in Spring of 2013, as the DSM-5) promises to be yet another major step forward, though not necessarily because of any dramatic reorganization in the diagnostic categories having to do with trauma and dissociation. What’s new (as I understand it) is (a) public access to the development process, due to first-time-ever use of the Internet, coupled with overt solicitation of public comment, and (b) the plan to have an online, updated edition of the DSM, which is why it’s being termed “DSM-5” and not “DSM-V”, so that there can be a “DSM-5.1”, etc. I strongly suspect that we’ll have to subscribe to keep current (or maybe access will come with purchase of the hard-copy version).

The final of three comment periods has opened – see Last Chance for Public Feedback on DSM-5 (this will give you an overview of the current status of the DSM-5 revision effort) and DSM-5 Draft Criteria Open for Final Public Comment – May 2nd through June 15th, 2012 (on the DSM-5 homepage).

Commenting is easy (but you will have to register with the DSM-5 website). However, be aware that many, if not all, of the work groups associated with various diagnostic categories have elicited research and recommendation papers from leading authorities on the relevant diagnoses, and familiarity with these papers (all that I’ve seen are available online) is a likely prerequisite for crafting of a valuable comment.

Their location is not highly visible at the DSM-5 website. Select an individual disorder, then the “rationale” tab on its page, and you’ll probably see the link. I offer two such links below. These review papers are well worth your attention, if you haven’t already seen them.

Finally, for a couple of  additional perspectives of central interest, consider looking at:

Enjoy!

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