DID

[driftingandlost]

Towards the end of my time in residency and coming out of a place where dissociative identity disorder is not regarded as a "real" diagnosis/condition. Was curious what the greater community (although I realize there's a bias posting on SDN) thought about it?

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[Sushirolls]

Definitely do a search, This one is well covered in this forum.

 

[Merovinge]

Here's my TLDR:
Based on known and systematically faked research out of Rush University.
Most modern research comes out of very few centers with heavy psychoanalytic bent in a select number of countries.
Heavy cross over (i.e. nearly 100%) in patient population with either borderline personality d/o or complex trauma.
Sexy as all get out for making TV shows and movies, highly popular to "discuss" symptoms on TicToc.

 

[comp1]

Borderline PD gets called so many different things, but it's still going to respond to a thorough DBT program.

 

[clozareal]

The split in the greater community on whether this exists is as much as the split in identities in DID patients.

 

[aim-agm]

I'm in the "probably not a real thing" camp, but I do have a patient that at least comes very close to meeting criteria and doesn't have borderline pathology. Criterion A is clearly met (although episodes are characterized primarily by depersonalization), and Criterion C is probably met, but while there is amnesia regarding trauma and the surrounding period of childhood that appears better explained by PTSD. Dissociative amnesia is certainly not associated with all episodes of dissociation, although cannot rule out presence in portion of episodes.

 

[Sushirolls]

DID

As someone working out of a forensic facility, there are moments when I feel like the diagnosis was made up by a group of clinicians whom were completely captivated by a BPD or ASPD presentation and missed the forest for the trees Have any of you actually come across a case of true DID? Is it a...

forums.studentdoctor.net

 

[deleted1100659]

Someone may see my response to this and and get annoyed at me, but to be honest I do not believe in it. At all. I believe people with a significant trauma history, often evolve into BPD, develop emotional dysregulation that manifests into different types of "sides of themselves". And the patient does not have the best insight, and misinterprets this as "alters". Among all the patients ive seen as a resident, and now as an attending, I cant think of one case that even seemed remotely authentic. So either its not real, or its so rare that most psychiatrists never encounter it.

On a side note, the new TV show Moon Knight, which the hero has DID, is quite good.

 

[romanticscience]

As someone interested in these types of patients, I have not experienced the classic "multiple personalities" either. However, I have had some pretty severe cases of BPD where there's some amnesia to behaviors that seemed motivated by a different "self-destructive" part of the patient behaving in a very different way towards me in the therapy.

This may be interesting to some: Herbert Spiegel, a late hypnotherapist, consulted on the patient behind the classic Sybil character and believed her identities were "suggested." I forget where I read this, but when he informed the primary psychiatrist, the Dr. said something like, "We already have a book deal!"

 

[alina_s]

Today a 12 year old told me they’d diagnosed “identity delusional disorder” in themself. I may have added to their frustration by not understanding what they meant.

 

[mistafab]

DID is fake news. The algos will make sure it continues to spread.

 

[Old&InTheWay]

Today a 12 year old told me they’d diagnosed “identity delusional disorder” in themself. I may have added to their frustration by not understanding what they meant.

Are they transracial?

 

[splik]

Because of my specialty foci on functional neurological disorders and hypnosis, I basically specialize in dissociative disorders. So I see far more patients who score highly on measures of dissociation than 99% of psychiatrists. I do see patients who have episodes where they are "not themselves" as reported by others with no recollection of their name or sense of who they are. I have also seen a lot of patients who have diagnoses of DID. I never diagnose this myself, but I have seen a very small number of patients who I have been convinced did have presentations of what could be regarded DID or dissociative fugue. However malingering is by far more common.

Going down the rabbit hole of what diagnoses are "genuine" or not really gets into more philosophical questions regarding the nature of mental disorder. Most psychiatric diagnoses are manufactured or invented. Most psychiatrists don't question the veracity of PTSD despite this being a diagnosis that was invented in the 1970s and gained traction for sociopolitical reasons as an indictment of the Vietnam War and a recognition of the war that women were fighting in their own homes involving sexual abuse, rape, and domestic violence. Schizophrenia is also not a legitimate disease entity and there are enormous problems with the concept of schizophrenia as a unitary phenomena. Much of the contemporary conception of schizophrenia is still neo-kraeplinian. You know we're in trouble when we're still relying on a century old model of madness.

The question in my mind is not whether a specific diagnostic construct is "real", but whether they are useful. We already know that the reliability and validity of almost all psychiatric diagnoses is laughably poor. However we continue to rely on common categories of mental disorder but they are a little bit useful in terms of communicating in shorthand and guiding treatment. While I have seen a small number of patients who have had convincing presentations of "alters" and other phenomena we see in DID, I have seen a much larger proportion of patients where this was clearly iatrogenic, suggested, factitious or malingered in origin. I do not see the utility of this as a specific diagnosis and instead regard this as an hysterical diagnosis, much like functional neurological disorder or even PTSD. Just as the term "somatoform" is used to describe medically unexplained physical symptoms in patients who tend to have a response style of pan-endorsing physical symptoms, and who are suggestible, the term "psychoform" has been used to describe these more dramatic presentations of psychiatric symptoms including multiple personalities etc. While the term hysteria has been abandoned for good reason, the concept itself is still a useful one and can be applied to patients with DID type presentations and help guide treatment.

Focusing on these elaborate presentations is to miss the point. Under the surface in non-malingered cases (whether hysterical or factitious), is usually someone in extreme emotional pain often having experienced unimaginable trauma who feels they have to hide this from others. Often these patients feel they need to be unique or special in order to be worthy of care or to captivate the attention of their therapists. The "DID" may serve as a defensive posture that derails more painful and much needed therapeutic work, allowing disavowal of more intense emotions or dangerous impulses, and prevent abandonment from the therapist.

 

[Stagg737]

Today a 12 year old told me they’d diagnosed “identity delusional disorder” in themself. I may have added to their frustration by not understanding what they meant.

I think "IDD" is probably a more reasonable explanation than DID for pretty much everyone claiming to have DID...

 

[Stagg737]

I'm generally agnostic and don't like absolutes so I'm not opposed to the idea that it's possible, but I haven't seen or reviewed any cases where I'd actually consider the diagnosis. I've had about a dozen patients I've seen who either carried a DID diagnosis or were adamant they had it. They almost always had BPD with some form of severe trauma and were fortunately agreeable to attempting trauma-focused therapies.

I have had one case that I've previously discussed on this forum a few years ago where we had a final diagnosis on a patient as dissociative fugue. However, he presented as severely depressed with extreme psychomotor ******ation to the point of near-catatonia all of which was questionably responsive to ECT. He later "snapped out of it" and couldn't recall the previous 5-6 months (roughly), though he never claimed to have any alternate personality or "alters". This was probably the closest thing to a true "functional", non-malingering, dissociative episode I've encountered.

I agree more with those in the camp who do not think it is an actual diagnosis as defined by the DSM, and that if it does truly exist in such a form that it is exceptionally rare.

 

[deleted1100659]

Today a 12 year old told me they’d diagnosed “identity delusional disorder” in themself. I may have added to their frustration by not understanding what they meant.

it means they wanted something fancy to put on their instagram/twitter with an associated hastag in order to obtain a sense of belonging. #DIDAWARENESS #DIDSURVIVOR.

seriously I see this kind of stuff so much these days..

 

[birchswing]

Because of my specialty foci on functional neurological disorders and hypnosis, I basically specialize in dissociative disorders. So I see far more patients who score highly on measures of dissociation than 99% of psychiatrists. I do see patients who have episodes where they are "not themselves" as reported by others with no recollection of their name or sense of who they are. I have also seen a lot of patients who have diagnoses of DID. I never diagnose this myself, but I have seen a very small number of patients who I have been convinced did have presentations of what could be regarded DID or dissociative fugue. However malingering is by far more common.

Going down the rabbit hole of what diagnoses are "genuine" or not really gets into more philosophical questions regarding the nature of mental disorder. Most psychiatric diagnoses are manufactured or invented. Most psychiatrists don't question the veracity of PTSD despite this being a diagnosis that was invented in the 1970s and gained traction for sociopolitical reasons as an indictment of the Vietnam War and a recognition of the war that women were fighting in their own homes involving sexual abuse, rape, and domestic violence. Schizophrenia is also not a legitimate disease entity and there are enormous problems with the concept of schizophrenia as a unitary phenomena. Much of the contemporary conception of schizophrenia is still neo-kraeplinian. You know we're in trouble when we're still relying on a century old model of madness.

The question in my mind is not whether a specific diagnostic construct is "real", but whether they are useful. We already know that the reliability and validity of almost all psychiatric diagnoses is laughably poor. However we continue to rely on common categories of mental disorder but they are a little bit useful in terms of communicating in shorthand and guiding treatment. While I have seen a small number of patients who have had convincing presentations of "alters" and other phenomena we see in DID, I have seen a much larger proportion of patients where this was clearly iatrogenic, suggested, factitious or malingered in origin. I do not see the utility of this as a specific diagnosis and instead regard this as an hysterical diagnosis, much like functional neurological disorder or even PTSD. Just as the term "somatoform" is used to describe medically unexplained physical symptoms in patients who tend to have a response style of pan-endorsing physical symptoms, and who are suggestible, the term "psychoform" has been used to describe these more dramatic presentations of psychiatric symptoms including multiple personalities etc. While the term hysteria has been abandoned for good reason, the concept itself is still a useful one and can be applied to patients with DID type presentations and help guide treatment.

Focusing on these elaborate presentations is to miss the point. Under the surface in non-malingered cases (whether hysterical or factitious), is usually someone in extreme emotional pain often having experienced unimaginable trauma who feels they have to hide this from others. Often these patients feel they need to be unique or special in order to be worthy of care or to captivate the attention of their therapists. The "DID" may serve as a defensive posture that derails more painful and much needed therapeutic work, allowing disavowal of more intense emotions or dangerous impulses, and prevent abandonment from the therapist.

This is a point I have always been very fascinated by. It does seem like there are biological clumpings of various types of suffering. But then there are ways that they manifest that are —less obviously than what you describe with DID--suggested by our environments. I really am curious how that works. Like I think about it even when it comes to nonpathological things like sexual orientation or gender identity being a thing. To me it seems obvious there are biologically different types of brains when it comes to gender/sex, but I am less convinced that there are these very clear distinctions between gender and sexual orientation, which is the current model of thinking about it. Another example is that I was told there are societies where breasts are not sexually arousing. Or that there were periods of time when anxiety manifested particularly in women with shaking hands much more than it does now. There must be very subtle cues around us that we can't see--some much more subtle than others. A cue subtle enough that would make a person's anxiety manifest differently if they lived in one decade rather than another—subtle in that we don't know why—but still incredibly powerful in the very real somatic end effect. That is a very interesting phenomenon. To me that's even more interesting than outer space exploration.

 

[nexus73]

From a medication standpoint, practically speaking, DID vs PTSD with dissociation vs BPD (with dissoc, plus depressed plus chronically anxious), there aren't different meds. Basically anti anxiety and antidepressant meds are what we try to use. There is no magic medicine you get for DID that you don't get for PTSD or BPD.

 

[splik]

From a medication standpoint, practically speaking, DID vs PTSD with dissociation vs BPD (with dissoc, plus depressed plus chronically anxious), there aren't different meds. Basically anti anxiety and antidepressant meds are what we try to use. There is no magic medicine you get for DID that you don't get for PTSD or BPD.

This reminds me there was an episode of Nip/Tuck many years ago where one of the patients supposedly had DID and her psychiatrist said the challenge is her alters may respond to different medications. One alter might respond to a TCA and the other needs an MAOI. It was ridiculous.

But practically speaking, pts with "DID" score more highly on measures of dissociation, than pts with PTSD or BPD. Patients with BPD don't tend to have high levels of dissociation (though they score more highly than pts with mood or anxiety disorders). Pts with dissociative disorders tend to be more somatically preoccupied and have all sorts of adverse effects with medications. They may also report becoming aggressive or violent with psychotropic medications or reporting worsening of dissociative symptoms or amnestic episodes. You have to be a lot more careful about drug treatment than you do with BPD (where there is often an initial placebo response followed by worsening). Also, while it is very common for pts with "DID" to have BPD, I have several pts with significant dissociative episodes who do not meet criteria for BPD.

 

[nexus73]

This reminds me there was an episode of Nip/Tuck many years ago where one of the patients supposedly had DID and her psychiatrist said the challenge is her alters may respond to different medications. One alter might respond to a TCA and the other needs an MAOI. It was ridiculous.

But practically speaking, pts with "DID" score more highly on measures of dissociation, than pts with PTSD or BPD. Patients with BPD don't tend to have high levels of dissociation (though they score more highly than pts with mood or anxiety disorders). Pts with dissociative disorders tend to be more somatically preoccupied and have all sorts of adverse effects with medications. They may also report becoming aggressive or violent with psychotropic medications or reporting worsening of dissociative symptoms or amnestic episodes. You have to be a lot more careful about drug treatment than you do with BPD (where there is often an initial placebo response followed by worsening). Also, while it is very common for pts with "DID" to have BPD, I have several pts with significant dissociative episodes who do not meet criteria for BPD.

This sort of nuanced thinking is too much. Just diagnose and prescribe I say.

 

[mistafab]

Just to touch on @splik s point, this in a broader sense comes down to the fact that the DSM is just a field guide for recognizing an entity, and allowing psychiatrists to speak a common language. I.e. a a guide on trees says if it has leaves shaped like this, drops leaves in the fall, gets this high in its height - it is probably a maple tree. We have meds for *maple tree disease.*

There is still a lack of causative factors leading to our diagnoses. Until that time we are still relying on “field guides“ like the dsm, which has many shortcomings but is the best we have. With our current system, we are vulnerable to manufactured diagnoses, pharma influence, etc. They as well as anyone can put forth “entity x” and say it exists, it becomes hard to say it isnt true. DID falls cleanly into that category. PMDD was heavily supported by the company that created prozac, hoping to expand that market. It is solidly in our dsm now - 80% of women described as having this “disorder” - now these people become patients, and candidates for pharmacotherapy.

 

[SeniorWrangler]

My rule of thumb is to figure out who signs the checks and work exclusively with them.

 

[Mad Jack]

I'm generally agnostic and don't like absolutes

So you're not a Sith, then

 

[Alemo]

Under the surface in non-malingered cases (whether hysterical or factitious)

Could you (or anyone) elaborate on the distinction between these two (if one exists)?

 

[smalltownpsych]

From a medication standpoint, practically speaking, DID vs PTSD with dissociation vs BPD (with dissoc, plus depressed plus chronically anxious), there aren't different meds. Basically anti anxiety and antidepressant meds are what we try to use. There is no magic medicine you get for DID that you don't get for PTSD or BPD.

Not a psychiatrist so i wouldn’t be able to prescribe, but I bet Obecalp is probably going to be more effective for DID than any other medication. Could be almost like magic.
That being said, I personally use DBT and exposure therapy to treat all of the above although it is extremely rare to get a true DID type patient and I have worked with a lot of traumatized dissociators. In other words, we are going to talk about bad stuff and connect the experiences to the words and the emotions as opposed to dissociating which is just another form of avoidance of thoughts of distressing events. Dissociating is a symptom and connecting to self and your world is the cure.

What is interesting is that I have had a number of patients receiving ketamine therapy for trauma and was able to accompany them during the infusion. The medicine clearly caused dissociation, if that is the correct term for that chemically induced state, but also every patient at some point during the infusion process or treatments went back to the trauma. It was clearly visible as they would shift. They were back there reliving it and it would often get to be too intense and the medical doctor we were working with would use sedatives to help calm the patient. These were extremely serious cases with serious trauma and other treatments were having little effect, but we made a lot of progress with the infusions coupled with intensive psychotherapy. Patients were also receiving a cocktail of regular psych meds to assist with managing their daily symptoms.

 

[alina_s]

Are they transracial?

I’ll never go there, this kid is way too suggestible. My cranky non-DSM diagnosis is too much time on the internet, although their self-diagnosis was pretty great.

 

[deleted1100659]

normally the DID patients also have comorbid metastatic fibromyalgia, mast cell disease, ehlers danlos, and POTs.

 

[octopuszebra]

Going down the rabbit hole of what diagnoses are "genuine" or not really gets into more philosophical questions regarding the nature of mental disorder. Most psychiatric diagnoses are manufactured or invented. Most psychiatrists don't question the veracity of PTSD despite this being a diagnosis that was invented in the 1970s and gained traction for sociopolitical reasons as an indictment of the Vietnam War and a recognition of the war that women were fighting in their own homes involving sexual abuse, rape, and domestic violence. Schizophrenia is also not a legitimate disease entity and there are enormous problems with the concept of schizophrenia as a unitary phenomena. Much of the contemporary conception of schizophrenia is still neo-kraeplinian. You know we're in trouble when we're still relying on a century old model of madness.

The question in my mind is not whether a specific diagnostic construct is "real", but whether they are useful. We already know that the reliability and validity of almost all psychiatric diagnoses is laughably poor. However we continue to rely on common categories of mental disorder but they are a little bit useful in terms of communicating in shorthand and guiding treatment.

I love your posts, splik, but I think I disagree with your claim about schizophrenia and I'd like to explore this further because I think it is important.

Let me lay out my viewpoint and perhaps you can tell me where you differ. I believe that the DSM-5 definition of schizophrenia is supported by a large body of clinical and research evidence and it is useful for guiding treatment. In this definition, schizophrenia is conceptualized as a disease or disorder (i.e., a clinical syndrome with biological underpinnings). Symptom severity is conceptualized as on a spectrum, with no one symptom or sign being diagnostic of schizophrenia. The symptoms must cause distress or impair functioning. Crucially, there must be a significant decline in functioning relative to the person's premorbid functioning; this cognitive decline is very much a Kraepelinian notion.

The definition delimits the construct of schizophrenia, such that some disorders that may appear similar (e.g., schizotypal disorder, brief psychotic disorder, and psychotic disorder due to another medical condition) are generally excluded from the diagnosis. The criteria incorporate positive symptoms (e.g., hallucinations, delusions, disorganized speech), negative symptoms (e.g., avolition, asociality), and cognitive symptoms (e.g., disorganized thinking, thought disorder, anosognosia). With diagnostic specifiers, the criteria can also incorporate mood symptoms (e.g., depressive symptoms, mood lability) that have been found to be empirically related to the disorder. The definition is broad enough to allow individual variation in the presentation of the disorder but strict enough to exclude some other disorders that may appear similar. Obviously, the definition is far from perfect and should continue to be refined, but I'm not sure what makes you claim that is not legitimate.

The notion that because a diagnostic model has been around for a century, we are "in trouble", is ridiculous and indeed backwards. The diagnostic model also helps clinicians, patients, families, and society at large to recognize that schizophrenia is a biological disorder and not a moral or spiritual failing.

If the diagnosis of schizophrenia is not legitimate, then how does it have a heritability of 60-80%? How do people with the highest centile of polygenic risk score for schizophrenia have an odds ratio of 39 for the disorder compared to people with the lowest centile and 5.6 compared to the remaining 99% of individuals?

I do agree however, that the term "schizophrenia" of course has been and sometimes continues to be overused and misused, and that many patients in the community who are diagnosed with schizophrenia do not have what would be called schizophrenia in a more strictly defined research setting.

I am motivated to continue to learn and I want to know where I am misguided. I would appreciate any insight or pointers you can provide.

 

[smalltownpsych]

I agree with Splik saying that schizophrenia as a disease entity isn’t legitimate. I don’t think he is saying that it isn’t real. In my mind, schizophrenia disorders are a great example of how our diagnostic system with its disregard of etiology is problematic. The key phrase he used, and I use frequently, is unitary construct. Research in our field and how it applies to clinical practice is a funny thing. In research, we intentionally exclude the unclear cases and in clinical practice it seems like that is all we see.

Research is reductionistic by design and necessity, but in clinical practice we have to treat the individual and they almost never seem to fit into the categories well. Bipolar Disorder and Schizophrenia are good examples of that. I have seen way too many cases where that line doesn’t seem very clear and the psychiatrist that I worked with would just throw lithium and clozapine at it. Then as they stabilized we would ask, should we decrease the lithium or the clozaril or just the zyprexa that was thrown into the mix to try to bring it all down in the acute phase. Meanwhile, some patients were more clearly manic only and others were more clearly psychotic disorder only. if we had better answers as to what these disorders were or weren‘t and where to draw some of these lines it would clearly guide treatment and help our patients.

 

[splik]

If the diagnosis of schizophrenia is not legitimate, then how does it have a heritability of 60-80%? How do people with the highest centile of polygenic risk score for schizophrenia have an odds ratio of 39 for the disorder compared to people with the lowest centile and 5.6 compared to the remaining 99% of individuals?

"schizophrenia" is a construct, largely based on the dementia praecox concept from Emil Krapelin, influenced along the way by Kurt Schneider's work. From DSM-III onwards, the neo-krapelinian version of schizophrenia had come back in vogue (the concept of schizophrenia in DSM-I and DSM-II was quite different, heavily influenced by Bleuler's version of schizophrenia which was more in keeping with Adolf Meyer's psychobiological model of psychiatry which was the prevailing vision of that era). I am not sure what it means for something to be a "biological disorder", and the evidence is convincing that neurobiological models of schizophrenia have increased the stigma and negative attitudes, rather than reduce it.

Krapelin took the "amorphous mass of madness" and carved "nature at the joints" into manic-depressive insanity and dementia praecox. Dementia praecox, as the forerunner of today's schizophrenia is supposed to be distinct from manic-depressive insanity (now bipolar disorder and recurrent depression). However many patients meet criteria for both disorders, despite this being an exclusion in the DSM. In addition, many patients overlap in syndromes, meeting criteria for schizoaffective disorder. Genetic research, far from validate the concept of schizophrenia has exploded the Krapelinian dichotomy given the large number of SNPs that have been associated with both disorders. Indeed, many of the GWAS studies have suggested a shared genetic risk between schizophrenia, bipolar disorder, autism spectrum disorder, ADHD and so on. This has shed light on differences synaptic processes and signalling pathways as being a non-specific shared pathway to a variety of psychopathological outcomes. Similarly, copy number variations, some of which confer a stronger risk for development of "schizophrenia" are not specific to this outcome and associated with intellectual disability, autism, ADHD, Tourettes etc.

Heritability estimates are typically based on twin studies. The early twin studies including popularizing the concept of schizotypal disorder, which was seen as a muted phenotype of schizophrenia, in order to buff up the numbers and strengthen the apparent association. Interestingly, some of the analyses in the past 25 years have included this data that now goes back many years. More recent studies have been found to bundle in mania, schizoaffective disorder, and even organic psychoses in the analyses. In addition high heritability has been shown for bipolar disorder in those with a family history of schizophrenia and vice versa. Again, this explodes the dichotomy of these as being biologically distinct disorders. Another limitation of twin studies is they do not control for environmental factors. Studies of adopted twins from mothers with schizophrenia show that environmental factors are indeed relevant to the risk of schizophrenia in MZ twins, and typically MZ twins share more environmental exposures than DZ twins. In the early days, it was believed that MZ twins would have identical brains but neuronal migration has been shown to be different in MZ twins as well.

Any psychiatric geneticist (including the senior author of the paper you cited and several co-authors) will tell you that schizophrenia is not a legitimate disease entity or unitary disorder and that this is what genetic research is telling us. One of the co-authors of the paper you cite (Jim Van Os) who was also on the DSM-5 committee for schizophrenia spectrum disorders has written extensively on why schizophrenia does not exist. Indeed, trying to genetic research on DSM constructs is one of the major limitations to psychiatric genetic research. This was one of the reasons why RDoC and other models had been proposed that might allow more fruitful inquiry (although that has its own limitations). I feel quite smug when I point out that it took the geneticists over 40 years to arrive at the same conclusion the social scientists reach long ago: schizophrenia is not a natural kind but a social construct. It is also a problem from the perspective of any neurobiological inquiry that the diagnosis relies of social values (e.g. impairment and distress).

I do not primarily work with pts with psychosis these days but it has been years since I have given someone a dx of schizophrenia in any meaningful sense and round here it doesn't seem to be encouraged or seen as particularly useful by those who work with this population.

 

[Alemo]

Thanks for that summary. Re: other nosologies like RDOC, I do wonder if DSM-“informed” research is completely useless (or worse, actively confounding our already limited understanding of these phenomena).

I haven’t given thought to what’s holding everyone back from switching to a simple description of symptoms (stripping off as many of the labels as possible), other than we would (again) lose a common shorthand for which to describe things. Everything could be reduced to its constituent parts (a la RDoC) and a patient might be described as having concentration problems, racing thoughts, paranoia, depressed mood, and delusions.

Categorized this way, we would lump many folks together in research arms that are currently explicitly separated (even though we know co-morbidity is the rule). This would be like studying say, all patients with (what used to be called) ADHD, GAD, and bipolar disorder.

Or we could all keep pretending that the DSM isn’t a dead end and carry on, looking for the next serotonin modulator that totally no foolin for sure this time definitely decreases agitation scores in “schizophrenia” (“vapors”).

 

[smalltownpsych]

Thanks for that summary. Re: other nosologies like RDOC, I do wonder if DSM-“informed” research is completely useless (or worse, actively confounding our already limited understanding of these phenomena).

I haven’t given thought to what’s holding everyone back from switching to a simple description of symptoms (stripping off as many of the labels as possible), other than we would (again) lose a common shorthand for which to describe things. Everything could be reduced to its constituent parts (a la RDoC) and a patient might be described as having concentration problems, racing thoughts, paranoia, depressed mood, and delusions.

Categorized this way, we would lump many folks together in research arms that are currently explicitly separated (even though we know co-morbidity is the rule). This would be like studying say, all patients with (what used to be called) ADHD, GAD, and bipolar disorder.

Or we could all keep pretending that the DSM isn’t a dead end and carry on, looking for the next serotonin modulator that totally no foolin for sure this time definitely decreases agitation scores in “schizophrenia” (“vapors”).

I agree with what you say except for the DSM being a dead end. I think we just need to recognize it for what it is and to recognize that grouping clusters of symptoms is just one step on the way. When we get etiology back into the mix and begin to get more effective diagnositc tools and also recognize that there is always an interplay between neurology and environment, there will likely be a leap to the next step, but then again my wife always says I'm too much of a Pollyanna.

 

[Alemo]

I agree with what you say except for the DSM being a dead end. I think we just need to recognize it for what it is and to recognize that grouping clusters of symptoms is just one step on the way. When we get etiology back into the mix and begin to get more effective diagnositc tools and also recognize that there is always an interplay between neuro,ogy and environment, there will likely be a leap to the next step, but then again my wife always says I'm too much of a Pollyanna.

Hey, we need Pollyannas and pessimists. If everyone was like me we’d still be hiding in caves stockpiling rocks for the next tribal war.

But, if I may, I do think it’s possible the DSM classifications are actively setting us back. If you are studying “macular rash syndrome” and only have antivirals to treat it, and then call (what is actually a hypersensitivity reaction) “treatment resistant viral macular rash syndrome” and conclude “we need to pump more money into antiviral development,” you’re screwed.

It’s not progress if you’re going the wrong way…

 

[smalltownpsych]

Hey, we need Pollyannas and pessimists. If everyone was like me we’d still be hiding in caves stockpiling rocks for the next tribal war.

But, if I may, I do think it’s possible the DSM classifications are actively setting us back. If you are studying “macular rash syndrome” and only have antivirals to treat it, and then call (what is actually a hypersensitivity reaction) “treatment resistant viral macular rash syndrome” and conclude “we need to pump more money into antiviral development,” you’re screwed.

It’s not progress if you’re going the wrong way…

I agree completely with this statement, but also know that people are challenging the pardigms and technology will play a role. One of my professors would talk about how limited our undserstanding of neuroscience was when Freud was around and that a lot of his flawed thining was due top the lack of tech advances that we take for granted now. For example, we couldn't really nail down the cause of certain diseases until youi could look through a microscope and see the little bacteria multiplying and then we had to figure out viruses because we couldn't see those yet. In short, we will throw out the DSM when we get something better and people are working on that from multiple angles. As a practicing clinician, I want them to hurry it up!

 

[clausewitz2]

Any psychiatric geneticist (including the senior author of the paper you cited and several co-authors) will tell you that schizophrenia is not a legitimate disease entity or unitary disorder and that this is what genetic research is telling us. One of the co-authors of the paper you cite (Jim Van Os) who was also on the DSM-5 committee for schizophrenia spectrum disorders has written extensively on why schizophrenia does not exist. Indeed, trying to genetic research on DSM constructs is one of the major limitations to psychiatric genetic research. This was one of the reasons why RDoC and other models had been proposed that might allow more fruitful inquiry (although that has its own limitations). I feel quite smug when I point out that it took the geneticists over 40 years to arrive at the same conclusion the social scientists reach long ago: schizophrenia is not a natural kind but a social construct. It is also a problem from the perspective of any neurobiological inquiry that the diagnosis relies of social values (e.g. impairment and distress).

I do not primarily work with pts with psychosis these days but it has been years since I have given someone a dx of schizophrenia in any meaningful sense and round here it doesn't seem to be encouraged or seen as particularly useful by those who work with this population.

I am still solidly in the psychosis space and can confirm, nobody serious in the field believes that schizophrenia is anything other than a historical and administrative label at this point. I talk to patients about intense unusual experiences that other people seem to have a hard time understanding, the problems of when your private experiences become more compelling and urgent-seeming than everything else happening around you, and the tremendous fear that paralyzes you when there is a threat you feel powerless against seems to be lurking everywhere, but "schizophrenia" only comes up in our early conversations when they either ask or I tell them, "here's a label you are going to hear people use, here's what they probably mean by it."


Hell, even Kraeplin himself later said that the cases that he couldn't really sort between manic-depressive insanity and dementia praecox were probably more numerous than the ones that clearly fell in one category or another.

I sometimes still think of folks who have what would have been called "process schizophrenia" in some traditions as "schizophrenia schizophrenia" in my head but this is my own informal shorthand for a pretty specific clinical picture. Similarly, I think we have all met the people who are very high functioning except when they get really floridly manic and improve tremendously with even a whiff of lithium; I think it was Paul Grof who suggested this should be called "Cade's disease". Outside of really strong prototypes these divisions are hard to sustain and at the end of the day even these pictures might just be the result of interactions of shared common pathways and very specific idiosyncratic factors.

 

[smalltownpsych]

I am still solidly in the psychosis space and can confirm, nobody serious in the field believes that schizophrenia is anything other than a historical and administrative label at this point. I talk to patients about intense unusual experiences that other people seem to have a hard time understanding, the problems of when your private experiences become more compelling and urgent-seeming than everything else happening around you, and the tremendous fear that paralyzes you when there is a threat you feel powerless against seems to be lurking everywhere, but "schizophrenia" only comes up in our early conversations when they either ask or I tell them, "here's a label you are going to hear people use, here's what they probably mean by it."


Hell, even Kraeplin himself later said that the cases that he couldn't really sort between manic-depressive insanity and dementia praecox were probably more numerous than the ones that clearly fell in one category or another.

I sometimes still think of folks who have what would have been called "process schizophrenia" in some traditions as "schizophrenia schizophrenia" in my head but this is my own informal shorthand for a pretty specific clinical picture. Similarly, I think we have all met the people who are very high functioning except when they get really floridly manic and improve tremendously with even a whiff of lithium; I think it was Paul Grof who suggested this should be called "Cade's disease". Outside of really strong prototypes these divisions are hard to sustain and at the end of the day even these pictures might just be the result of interactions of shared common pathways and very specific idiosyncratic factors.

Thanks for the reference to that concept, hadn’t heard of it. There are problems with diagnosis by response to medications; nevertheless, it can often point to some unknown neurobiological mechanism that differentiates cases. I have noticed that some of my patients with depression have a strong family history, often have symtpom severity that seems less tied to environmental or interpersonal events and seem to respond better to SSRI. Others where it seems clearly tied to trauma and other adverse environmental events and they tend to get lots of medicines that never really seem to help. Of course, really bad things can also happen to the first group and cloud that picture. There is also the dynamic of growing up with a severely depressed parent to throw in the mix.

 

[Ceke2002]

I do wonder if the current (apparent) upswing in folks claiming a diagnosis of DID is a continuation of a trend I noticed on mental health support boards several years back. Certain diagnoses were seen as more 'desirable' based on the perceived level of care, or attention, one would receive; so, for example, borderline personality disorder was an undesirable diagnosis to receive based on perceptions that care would be inadequate and health care professionals would generally be dismissive, whereas something like DID would potentially at least garner someone more attention and perhaps a better level of care from the right clinician. Oddly enough noone ever seemed to stop and think that the right clinician would also provide the correct amount of care and attention to a BPD patient as well. But yeah there was definitely an interesting little hierarchy of diagnoses going on with the support communities at one time.

From a layperson's point of view I would also have to say out of several folks I met over a number of years, who claimed to be diagnosed with DID, there was only one who I personally believed might've been genuine (for a number of reasons I won't bore people with).

Nice to see some familiar faces around again as well.

 

[DynamicDidactic]

I think this review is relevant to the discussion

Dissociation and Dissociative Disorders Reconsidered: Beyond Sociocognitive and Trauma Models Toward a Transtheoretical Framework

For more than 30 years, the posttraumatic model (PTM) and the sociocognitive model (SCM) of dissociation have vied for attention and empirical support. We contend that neither perspective provides a satisfactory account and that dissociation and dissociative disorders (e.g...

www.annualreviews.org