Article commenting on ideal basis for DSM-V

[TreeOfSouls]

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Interested in hearing (well, reading) your thoughts/comments:

http://dana.org/news/cerebrum/detail.aspx?id=23560

 

[393656]

Interested in hearing (well, reading) your thoughts/comments:

http://dana.org/news/cerebrum/detail.aspx?id=23560

What a stupid article. Blaming dsm for making psych "boring." Its clinicians like them that treat DSM as the end all, be all of their diagnostic evaluations and practice. Nobody ever tells you that DSM has to guide everything you do. It is a set of symptoms and checklists to help standarize diagnosis and billing/coding across practioners and insurance. They are a GUIDE and only a SMALL part of a patients evaluation and treatment. Its maybe 25 percent of the make-up of my evaluation of the patient.

Its clinicians own fault if they are relying too much on the DSM for identifying a proper diagnostic evaluation of a patient. Silliness

 

[nitemagi]

Agreed. It is purposely atheoretical as to etiology, so that we can at least agree on what we're talking about. But of course that has drawbacks as well.

It's an ok starting point. But that's all it is.

 

[TreeOfSouls]

It seems that the authors were suggesting that merely focusing on categorization is a major limitation of the DSM and were advocating that it should provide more than just "a starting point" for psychiatrists since much more is known about psychiatric problems than just their general symptoms.

 

[billypilgrim37]

What a stupid article. Blaming dsm for making psych "boring."

I think you missed the point of the article.

 

[393656]

It seems that the authors were suggesting that merely focusing on categorization is a major limitation of the DSM and were advocating that it should provide more than just "a starting point" for psychiatrists since much more is known about psychiatric problems than just their general symptoms.

Really? Other than psychopharm knowledge we really have not advanced all that far in understanding pathophysiology of any of our mental illness. Sure we have identified many genes and such but have not put it into any useful practice. Maybe ISPOT will be the first to start to do that with functional EEG.

The DSM pretty much does sum up what we know-which is really squat. That is why its only one small tool to make sure multiple different doctors can treat someone and be on the same page.

Thinking of disorders in more of a spectrum fashion is something many accept but we definetly have very little "evidence" We have some good genetic evidence that bipolar is related to schizophrenia much more than ever thought but hardly a widely accepted proposition.

Sadly we really do not have a heck of a lot more knowledge and DSM pretty much does what it can with our limited amt of info. Pesronally I am a spectrum believer in everything and would have spectrums for each diagnsos so its not so black and white. Other than that sadly we dont know much in psychiatry

 

[Manicsleep]

We have to have a coding system and a billing system.
THe DSM is a framework for that and a guide as others have said. The problems begin when non psychiatrists start using it as a bible (and some psychiatrists actually).

It does the job its meant to do reasonably well, just don't try to overclock it.

 

[Suedehead]

We have to have a coding system and a billing system.
THe DSM is a framework for that and a guide as others have said. The problems begin when non psychiatrists start using it as a bible (and some psychiatrists actually).

It does the job its meant to do reasonably well, just don't try to overclock it.

Most psychiatrists....

 

[billypilgrim37]

As imperfect as the DSM is, OUR ENTIRE EVIDENCE BASE OF KNOWLEDGE for treatment is linked directly to it. If you're not using the DSM, then you have essentially zero evidence for anything you're doing other than "experience" and the mad late night ramblings of Steven Stahl. If you are using it, you're treating unicorns and leprechauns and other things that don't exist. But at least you know you're treating things that don't exist with some understanding that people have a chance of getting better from what other non-mythical thing they may have going on.

 

[393656]

As imperfect as the DSM is, OUR ENTIRE EVIDENCE BASE OF KNOWLEDGE for treatment is linked directly to it. If you're not using the DSM, then you have essentially zero evidence for anything you're doing other than "experience" and the mad late night ramblings of Steven Stahl. If you are using it, you're treating unicorns and leprechauns and other things that don't exist. But at least you know you're treating things that don't exist with some understanding that people have a chance of getting better from what other non-mythical thing they may have going on.

Sorry to break it to you but the DSM is linked to absolutely NO evidence regarding treatment. It also has no information about genetics. Are you saying the many current genetic links proven are not "evidenced based" The DSM lags way behind and again has absolutely nothing at all to do with evidence based treatment. Are you living under a rock or have you read the dsm?

 

[billypilgrim37]

Sorry to break it to you but the DSM is linked to absolutely NO evidence regarding treatment. It also has no information about genetics. Are you saying the many current genetic links proven are not "evidenced based" The DSM lags way behind and again has absolutely nothing at all to do with evidence based treatment. Are you living under a rock or have you read the dsm?

We have fictional approximations of discrete illnesses in the DSM. We recruit people to studies based on whether they SCID on to an illness in the DSM. We give them treatments or not, and then report the results. Then, the FDA says whether something is a valid treatment for a DSM disorder, and insurance companies are willing to pay for the treatment based on largely whether the pt a) has an illness as defined in the DSM, and b) whether that treatment is considered an acceptable treatment for that DSM disorder. That's the majority of our clinical trial evidence. Most of our studies do not address particular symptoms or circuits or biomarkers. They address DSM categories.

So, since evidence-based treatment doesn't substantially exist without the DSM as a reference point, I'm not really sure what you mean when you say it has nothing to do with evidence-based treatment. The NIMH would be very confused about this statement, as would the FDA.

 

[393656]

If that is what you think great. In short the DSM at this point represents very little of cutting edge evidence emerging in both understanding and treatment. It offers a mechanism for billing IMO. I do not think of mood disorders is discreet entities anymore and nor does virtually every psychiatrist I can think of, spectrum disease is a much more realistic way to think about it and it matches up with our treatment much better. I do not agree and nor do most people that bipolarity is on a spectrum with MDD anymore but rather is on a psychotic spectrum likely more related to schizophrenia. Again which dictates and explains why they respond to similar treatment.

If you need the DSM to guide you than great. It is a general guide for me but that is all. Definetly does not influence evidence based prescribing. How could it-its from the 90s? You must be saying there has been no evidenced based progress since than which clearly is absolutely hogwash

 

[billypilgrim37]

I'm not sure what part of my post was an opinion. I don't get the sense we're talking about the same thing at all.

 

[393656]

Basically you think the dsm is the what guides our evidence based treatments and I completely disagree considering dsm does not address treatment. Simple as that

 

[dl2dp2]

If that is what you think great. In short the DSM at this point represents very little of cutting edge evidence emerging in both understanding and treatment. It offers a mechanism for billing IMO. I do not think of mood disorders is discreet entities anymore and nor does virtually every psychiatrist I can think of, spectrum disease is a much more realistic way to think about it and it matches up with our treatment much better. I do not agree and nor do most people that bipolarity is on a spectrum with MDD anymore but rather is on a psychotic spectrum likely more related to schizophrenia. Again which dictates and explains why they respond to similar treatment.

What you are talking about is being implemented in DSM V in the "dimensional system." Also, method using current knowledge of correlating symptoms with neuro circuitry is being used, i.e. RDoC (http://www.nimh.nih.gov/research-funding/rdoc.shtml)

DSM is a starting point, and while it's true we don't know much about the brain, we do know SOMETHINGs from neuroscience and psychopharm/longitudinal studies. And NIMH/DSM task force is trying very hard to incorporate these things into the next DSM. Older generation though is resistant to this. Neuroscience is on its way to replace old guard theories as a foundation to psychiatry.

 

[billypilgrim37]

Basically you think the dsm is the what guides our evidence based treatments

I don't *think* the DSM is what guides our evidence-based treatment. I know so by looking at the methods section of almost every clinical trial that has been conducted in the past 20 years. I don't understand where the debate is for this. This is not an opinion. This is a definition.

I'm not saying "the DSM is right," "the DSM includes up to date knowledge," or "the DSM is the best way to understand what is going on." These latter statements are absurdly untrue, of course. There will be significant, underappreciated improvements in DSM5, but its limitations will still be legion. But it will be a paradigm we can grow with more easily for the future.

Sure, you can take a history, formulate a thoughtful assessment based on any of a number of very good paradigms, prescribe a treatment based upon that paradigm, and be a great psychiatrist. That's what the vast majority of us do most of the time, and more than just the DSM or any one paradigm informs our assessment and allows us to formulate a treatment plan.

I get this is largely a semantic argument, but it's an important one. You can't begin to understand how to apply the evidence base to the real patients you see until you understand that the evidence-base depends on the qualities and limitations of the DSM and research instruments it has spawned.

and I completely disagree considering dsm does not address treatment. Simple as that

And that has nothing to do with anything. The Bible isn't a science textbook, Bob Dylan isn't an opera singer, and I can't dunk a basketball. Each of these things are just as relevant as the dsm addressing treatment. THE VAST MAJORITY OF OUR TREATMENT LITERATURE since the mid-80s relies upon DSM diagnoses. They simply do. I'm not making it up. It's not an opinion. It's simply looking at the methods section of the papers.

The literature addresses treatment. The literature does this using DSM diagnoses. Researchers don't lick patients on the cheek and decide whether they taste bipolar or not. They adminster SCIDs. We do clinical interviews, but we have to understand that when we prescribe treatment based upon our assessment and understanding of the literature that we are adapting the results of studies that depend upon a flawed means of assessment. And we do the best we can. And most of the time we probably do a lot better job for our patients with our eclectic styles. But we'd fool ourselves if we said what we were doing wasn't vastly different than what was done in a research study that gives us the little bit of science we utilize to try to help our patients.

And I'll let you have the final word, because I've clearly spent too many words on something we could probably settle in 5 minutes over a cup of coffee.

 

[TreeOfSouls]

It seems like maybe there is some debate about how much of psychiatry diagnosis is "evidence based" and how much of psychiatry treatment is "evidence based"? Would it be fair to say that more of the treatment is evidence based whereas less of the diagnosis is evidence based? What do you see as the major evidence based diagnoses and treatments? (which may be an interesting question given that the mechanisms of some medications with regard to why they are helpful is not known/clear)

 

[nitemagi]

I heard a speaker describe the DSM as developed by the BOGSAT's method.
[Bunch Of Guys Sitting Around Talking]. The diagnoses were developed by a consensus of experts in the field. That is a level of evidence, but different than prospective validation of the diagnostic categories. What BillyPilgrim seems to be saying (correct me if I'm wrong, I don't mean to speak for you) is that the DSM is used as the basis for a lot of the research that has come since then, meaning if one is looking at a treatment for anxiety then one first has to recruit patients that meet criteria for panic disorder, or GAD.

I disagree, though, with this last point. Much research looks at changes in specific scales, rather than SCID based interviews. I say MUCH, not all but I might say a minority (less than half). More common would be looking at a decrement on Ham-D, or PANSS. The inclusion criteria then becomes either a) a SCID based diagnosis or b) being diagnosed with X by a clinician (psychiatrist or psychologist. In the latter case the presumption is they're following DSM criteria, but having worked in research I cultivate a health skepticism.

 

[billypilgrim37]

I disagree, though, with this last point. Much research looks at changes in specific scales, rather than SCID based interviews. I say MUCH, not all but I might say a minority (less than half). More common would be looking at a decrement on Ham-D, or PANSS. The inclusion criteria then becomes either a) a SCID based diagnosis or b) being diagnosed with X by a clinician (psychiatrist or psychologist. In the latter case the presumption is they're following DSM criteria, but having worked in research I cultivate a health skepticism.

This is certainly a fair point, but the scales themselves were not developed in a vacuum independent of DSM. As to your last statement, well, they TOLD NIMH they were going to diagnose by DSM criteria when they submitted the grant, whether they are or not. 😉 And they're still diagnosing with a DSM diagnosis, whether they are obeying criteria or not.

We all learned in medical school that DSM has problems. As psychiatrists, we have be able to discuss that with more nuance than "it's worthless" or "it's a billing manual." For all of it's imperfections, it's an important part of our field, and we can't just throw it under the bus without qualification.

And curse you for drawing me out of my self-imposed "I'm not gonna say anymore" sanction! 😉

While I'm not always on board with absolutely everything Naessir Ghaemi has to say, I'm not sure that what I'm saying is much different from many of the arguments he makes.

 

[393656]

Clearly you will not get it. Of course they need some inclusion method for studies but you are very wrong if you think the dsm is used for anything more than inclusion of patients. Rating scales are the hallmark of studies and you would need to argue that its those scales are the basis for evidence basd studies.

Also this still has nothing to do with guiding your treatment. YOU mentioned this about treatment.

Its not worth arguing about thought-I will wave the flag and concede!