ICD vs DSM! useful or useless ??

[ariesq8]

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hey there,
since im a new assistant in psychiatry, ive been struggling when it came to guidelines .. actually .. ok, this is going to sound so ignorant coming out of a newbie in the field but seriously NONE OF THEM sounds right !! i mean, the ICD and DSM diagnostic criteria seems so broad to me and my mind cant seem to accept them lol .. ahhhh i dont think ive explained myself well enough and im having hard time doing that,
my point is, i feel like we need to have strong neuroscience basics in which we should build the diagnosis on ..
ive been going through kaplan book of psychiatry and a friend of mine suggested i should read fish psychopathology but none of these books could satisfy my thirst for knowledge ..

where can i get scientific FACTS in which i could understand mental illnesses better and thus be able to diagnose !!

and to be honest, DSM seems unrealiable .. i think the ICD sounds more clinical oriented but again, it doesnt draw a clear cut line for diseases ..

ahhhh im so confused 😛

 

[nitemagi]

Take a breath. Relax.

The system is frustrating to all of us. There is no comprehensive perfect system to understand mental illness, yet. The DSM is meant to be atheoretical, and the neuroscience isn't really there to parse out the different illnesses. Especially if you talk to researchers in the neuroscience realm, they can tell you how soft many of the studies are.

When I teach medical students about psychiatry, I compare it to physics.

Remember when you were a little kid, what were you taught?
That atoms are the smallest particle there is.

Then you get to basic/high school physics and what do you learn?
Well actually there's these protons, and neutrons, and electrons.

Then when you get to college physics?
Well actually electrons aren't really particles, they're "clouds," and really they exist in a probability rather than a specific location.

And then grad school?
Quarks, string theory, etc.

Each step is important as a foundation, and as you get more sophisticated you somewhat have to unlearn what you already know, because the system is so complex. Jumping straight to string theory without any basic foundational understanding of the universe is too fast and fraught with problems.

For psychiatry you learn the DSM (ICD blue book is good too), and then in many ways you unlearn it. The more you read, the more you recognize there are increasingly complex ways to understand the system. The DSM does a symptom list, IMO for the purpose of just making sure we're all talking about the same thing, to be able to move the field forward. Then learn a phenomenological approach to the field. Then a neuroscience or basic science. Then a psychodynamic. Then a forensic. Then a cross-cultural. And there's pioneering research in each of these areas that continually redefines everything we knew before.

The brain is the most complex thing in the world. We're still working on understanding it 😉

It's your frustration that makes many of us interested in doing solid research, to continue to move the field forward.

 

[splik]

hey there,
since im a new assistant in psychiatry, ive been struggling when it came to guidelines .. actually .. ok, this is going to sound so ignorant coming out of a newbie in the field but seriously NONE OF THEM sounds right !! i mean, the ICD and DSM diagnostic criteria seems so broad to me and my mind cant seem to accept them lol .. ahhhh i dont think ive explained myself well enough and im having hard time doing that,
my point is, i feel like we need to have strong neuroscience basics in which we should build the diagnosis on ..
ive been going through kaplan book of psychiatry and a friend of mine suggested i should read fish psychopathology but none of these books could satisfy my thirst for knowledge ..

where can i get scientific FACTS in which i could understand mental illnesses better and thus be able to diagnose !!

and to be honest, DSM seems unrealiable .. i think the ICD sounds more clinical oriented but again, it doesnt draw a clear cut line for diseases ..

ahhhh im so confused 😛

you are conflating different terms here: issues or reliability, validity and utility of diagnoses. As a general rule DSM-IV diagnoses are very reliable. In the 1970s there was an important study called the UK/US diagnostic study which found that psychiatrists in New York were diagnosing schizophrenia far more commonly than were psychiatrists in London. The reason being American psychodynamic psychiatry had a much more fluid concept of what was schizophrenia than did European kraepelinian psychiatry. (Also we had lithium in Europe and no one was using lithium in the US). As a result of this and other challenges to the reliability of psychiatric disorders e.g. the Rosenhan study, the DSM-III working group was set up with the aim of operationalising diagnostic criteria for mental disorders. As a result if you are trained in making DSM-IV diagnoses then you can reliably make most diagnoses. Reliability means that if a patient presents to 10 different doctors they will more or less make the same diagnosis. DSM diagnoses are slightly more reliable than ICD-10 as it is a bit more of a cook-book approach. The DCR-10 is a particular reliable guide to making ICD-10 diagnoses and is used in research.

The problem is most psychiatric diagnoses are not valid (exceptions are Alzheimer's dementia, Lewy Body dementia etc). There is no validity to diagnoses such as schizophrenia, bipolar disorder, major depressive disorder and so on. These diagnoses are NOT diseases (or if they are there is no evidence to support this). They currently have no external validity in reality, and certainly no biological validity. Most of the biomarkers from research are very weak, with low rates of replication, and in particular a lack of specificity. Many people working in psychiatric genetics have now admitted that the main problem with doing psychiatric research is it is based on the assumption that 'schizophrenia' and so on are real diseases, and universal concepts. However, many of the candidate genes for schizophrenia are also candidate genes for bipolar disorder or major depression or panic disorder... and about 1% of cases of schizophrenia have been attributed to variable large chromosomal microdeletions (including 22.q11). What we are probably looking at with schizophrenia, bipolar and so on are different diseases with a similar manifestations. That is these disorders are syndromes that we have out of necessity lumped into imperfect categories. This highlights the limitations of the categorical approach to diagnosis.

The final issue with diagnoses are how useful are they? As a clinician my primary interest is in how useful my diagnoses are to my patients and I think many diagnoses are useful, but I could probably do without most of the diagnoses in DSM-IV.
If we take the example of bipolar disorder it is useful to me in the following ways:

1. making the diagnosis guides me with treatment - so I would start with mood stabilisers and then therapy for bipolar, but would start with DBT or MBT for borderline PD and avoid medication altogether; similarly I may prescribe antidepressants for a patient with major depression, but I would be concerned about destabilising or worsening illness with antidepressant monotherapy in bipolar

2. although there can be harm from giving someone a 'label' many of my patients find it useful. it means they don't feel alone with their suffering, there are support groups, and it means they think i understand the problem and can help

3. diagnoses allow access to benefits/welfare and protection under disability discrimination

4. DSM-IV diagnoses, because they are reliable if not valid, give us a common language for us to communicate with other colleagues. But they are also important in the legal setting as well. as one psychiatrist commented upon discussing whether we should abandon the diagnosis of schizophrenia altogether: "what would expert witness say when giving evidence? that a patient has the illness formerly known as schizophrenia?" Also diagnoses are important in terms of billing and getting reimbursements from insurance companies. I don't agree with this, but that is how it currently is.

So to answer your question: are DSM-IV/ICD-10 diagnoses useful - many of them are but most of them are probably BS. are they reliable - yes when made by an experienced clinician and especially if using the SCID or SCAN (semistructured interviews). are they valid - NO.

 

[splik]

I would recommend reading the following:

Fish's clinical psychopathology (the Max Hamilton one not the current version)

General Psychopathology by Karl Jaspers (this is a weighty two-volume tombe and it is very difficult to read in parts but a joy to read in others. I am very sceptical of people who claim to understand Jaspers)

Manic-Depressive Insanity and Paranoia by Emil Krapelin (DSM-IV is often said to be neokraepelinian. He may not have been the brightest spark, but Kraepelin's descriptions of the manic-depressive insanity are excellent)

Dementia Praecox: or the group of schizophrenias by Eugen Bleuler (Bleuler's schizophrenia is what influenced the American concept of schizophrenia as it was more aligned with psychodynamic concepts that Kraepelin's description of a hereditary degenerative disease)

Making us crazy: DSM: the psychiatric bible and the creation of mental disorders (excellent analysis of the mass proliferation of mental disorders which began with DSM-III although do read with a critical eye)

Madness and Civilisation by Michel Foucault (Foucault most likely became interested in psychiatry because he saw a psychiatrist as a young man who diagnosed him as homosexual. As a result he became very interested in the concept of how abnormality was constructed and how each era woud have a different discourse for conceptualising this. Foucault never let the facts get in the way of a good story, but he nonetheless makes some excellent points on the social construction of deviance and I think the most important thing Foucault contributed was that newer conceptualisations are not necessarily any better, they are just different.)

 

[PETRAN]

you are conflating different terms here: issues or reliability, validity and utility of diagnoses. As a general rule DSM-IV diagnoses are very reliable. In the 1970s there was an important study called the UK/US diagnostic study which found that psychiatrists in New York were diagnosing schizophrenia far more commonly than were psychiatrists in London. The reason being American psychodynamic psychiatry had a much more fluid concept of what was schizophrenia than did European kraepelinian psychiatry. (Also we had lithium in Europe and no one was using lithium in the US). As a result of this and other challenges to the reliability of psychiatric disorders e.g. the Rosenhan study, the DSM-III working group was set up with the aim of operationalising diagnostic criteria for mental disorders. As a result if you are trained in making DSM-IV diagnoses then you can reliably make most diagnoses. Reliability means that if a patient presents to 10 different doctors they will more or less make the same diagnosis. DSM diagnoses are slightly more reliable than ICD-10 as it is a bit more of a cook-book approach. The DCR-10 is a particular reliable guide to making ICD-10 diagnoses and is used in research.

The problem is most psychiatric diagnoses are not valid (exceptions are Alzheimer's dementia, Lewy Body dementia etc). There is no validity to diagnoses such as schizophrenia, bipolar disorder, major depressive disorder and so on. These diagnoses are NOT diseases (or if they are there is no evidence to support this). They currently have no external validity in reality, and certainly no biological validity. Most of the biomarkers from research are very weak, with low rates of replication, and in particular a lack of specificity. Many people working in psychiatric genetics have now admitted that the main problem with doing psychiatric research is it is based on the assumption that 'schizophrenia' and so on are real diseases, and universal concepts. However, many of the candidate genes for schizophrenia are also candidate genes for bipolar disorder or major depression or panic disorder... and about 1% of cases of schizophrenia have been attributed to variable large chromosomal microdeletions (including 22.q11). What we are probably looking at with schizophrenia, bipolar and so on are different diseases with a similar manifestations. That is these disorders are syndromes that we have out of necessity lumped into imperfect categories. This highlights the limitations of the categorical approach to diagnosis.

The final issue with diagnoses are how useful are they? As a clinician my primary interest is in how useful my diagnoses are to my patients and I think many diagnoses are useful, but I could probably do without most of the diagnoses in DSM-IV.
If we take the example of bipolar disorder it is useful to me in the following ways:

1. making the diagnosis guides me with treatment - so I would start with mood stabilisers and then therapy for bipolar, but would start with DBT or MBT for borderline PD and avoid medication altogether; similarly I may prescribe antidepressants for a patient with major depression, but I would be concerned about destabilising or worsening illness with antidepressant monotherapy in bipolar

2. although there can be harm from giving someone a 'label' many of my patients find it useful. it means they don't feel alone with their suffering, there are support groups, and it means they think i understand the problem and can help

3. diagnoses allow access to benefits/welfare and protection under disability discrimination

4. DSM-IV diagnoses, because they are reliable if not valid, give us a common language for us to communicate with other colleagues. But they are also important in the legal setting as well. as one psychiatrist commented upon discussing whether we should abandon the diagnosis of schizophrenia altogether: "what would expert witness say when giving evidence? that a patient has the illness formerly known as schizophrenia?" Also diagnoses are important in terms of billing and getting reimbursements from insurance companies. I don't agree with this, but that is how it currently is.

So to answer your question: are DSM-IV/ICD-10 diagnoses useful - many of them are but most of them are probably BS. are they reliable - yes when made by an experienced clinician and especially if using the SCID or SCAN (semistructured interviews). are they valid - NO.

+1


This is an excellent post. Will read again

 

[roubs]

There is no validity to diagnoses such as schizophrenia, bipolar disorder, major depressive disorder and so on. These diagnoses are NOT diseases (or if they are there is no evidence to support this). They currently have no external validity in reality, and certainly no biological validity. Most of the biomarkers from research are very weak, with low rates of replication, and in particular a lack of specificity. Many people working in psychiatric genetics have now admitted that the main problem with doing psychiatric research is it is based on the assumption that 'schizophrenia' and so on are real diseases, and universal concepts. However, many of the candidate genes for schizophrenia are also candidate genes for bipolar disorder or major depression or panic disorder...

Most psychiatrists I've worked with would agree with this, but when it comes to discussing what pharmacotherapy actually does there is a strong resistance to questioning whether antipsychotics are actually anti - psychosis and so on with the other drugs. When the constructs like psychosis, bipolar disorder, themselves aren't biologically established as they are elsewhere in medicine, it's interesting that theres hostility towards questioning what the anti-construct drugs actually do. I'm well aware they provide symptom relief so I'm not trying to come off like another non-M.D. railing against drugs and advocating angel therapy, but from a perspective outside medicine it seems like you took the model that was in place for the rest of physical medicine and put it down on top of a much messier situation.

 

[ariesq8]

splik :
wow thats convincing 😛 thanks mate and im reading fish right now, almost half way through but this is a descriptive book, im looking for a biological explanation ..

so what do you tell your patients ? that we are still clueless about their diseases ? wont that cost us their trust ?

 

[nitemagi]

Most psychiatrists I've worked with would agree with this, but when it comes to discussing what pharmacotherapy actually does there is a strong resistance to questioning whether antipsychotics are actually anti - psychosis and so on with the other drugs. When the constructs like psychosis, bipolar disorder, themselves aren't biologically established as they are elsewhere in medicine, it's interesting that theres hostility towards questioning what the anti-construct drugs actually do. I'm well aware they provide symptom relief so I'm not trying to come off like another non-M.D. railing against drugs and advocating angel therapy, but from a perspective outside medicine it seems like you took the model that was in place for the rest of physical medicine and put it down on top of a much messier situation.

I would distinguish taking issue with constructs of syndromes, from the idea of a construct of symptoms. We have good evidence that symptoms improve from medications, with good reliability and validity to measures of symptoms (not that all providers use such measures), and to improvement with the medications using the same measures. The syndromes are fuzzier.

 

[roubs]

^ You are spot on, it just seems like many patients are under the impression that their syndromes are being treated by the medications. This may be because the medications are grouped with anti-syndrome names and are marketed to treat syndromes. If the distinction you make was better understood its possible more patients would pursue combined somatic & psychosocial treatment.


..and with the increased demand for our traditional services you would see psychologists everywhere abandon RxP.

 

[nitemagi]

^ You are spot on, it just seems like many patients are under the impression that their syndromes are being treated by the medications. This may be because the medications are grouped with anti-syndrome names and are marketed to treat syndromes. If the distinction you make was better understood its possible more patients would pursue combined somatic & psychosocial treatment.


..and with the increased demand for our traditional services you would see psychologists everywhere abandon RxP.

Great points. I believe some of this is attributable to the DSM, but other factors include the insidious information campaigns of Big Pharma. Besides all the ADHD onslaught (and domination of CME trainings in this area), I've also noticed a shift from insomnia being discussed as a secondary insomnia to a syndrome to be treated independently (because that gives a market for new meds that target sleep only). Some say there's a similar trend in education and marketing for Female Sexual Arousal Disorder.

Pt.'s are often even less educated than non-mental health medical professionals, and so buy into whatever is sold to them. Especially when it is exculpatory for their problems ("it's not my fault I beat people up, it's my bipolar.")

 

[Ibid]

Great points. I believe some of this is attributable to the DSM, but other factors include the insidious information campaigns of Big Pharma,

Yes, but please don't think I am trying to rub you up the wrong way but it's not as if anyone who was in a position to do so ever tried or tries to dispell the pharma misinformation. It has rather suited "some" to let this point slide because perhaps it rather suited them to do so.

Again I'm not trying to rub you up but I think that point should be made nonetheless.

 

[roubs]

Yes, but please don't think I am trying to rub you up the wrong way but it's not as if anyone who was in a position to do so ever tried or tries to dispell the pharma misinformation. It has rather suited "some" to let this point slide because perhaps it rather suited them to do so.

Again I'm not trying to rub you up but I think that point should be made nonetheless.

Yes, I think we could all do with less rubbing up--and I'd wager that all mental health professionals vary as far as how well they explain treatments to patients. Many psychiatrists explain the limitations of medication, and some do not. Those who do non-medical interventions should likewise be explaining the risks, benefits and limitations of their treatments. I'm sure not all of them do it (well) either.

 

[nitemagi]

Yes, but please don't think I am trying to rub you up the wrong way but it's not as if anyone who was in a position to do so ever tried or tries to dispell the pharma misinformation. It has rather suited "some" to let this point slide because perhaps it rather suited them to do so.

Again I'm not trying to rub you up but I think that point should be made nonetheless.

It serves the pharma people because they make money from it. Of course they'll never educate others as to their motives, and in fact outright deny it.

The academics who do CME's and further this agenda fall into many camps - some do legitimate research in the area and are happy when given the microphone to advertise an idea, maybe unknowingly or knowingly furthering the other agenda of pharma.

Most people don't have malignant motives, they just don't know how to differentiate good science from bad, and rarely have the time to do it either.

If you're insinuating that it serves psychiatrists interests to further a model of "brain chemistry imbalance" and treating such imbalances with medications, because that's where the money is, there's definite truth in that. And it's too bad that RxP is also following the money in trying to get into that.

It saddens me to see so many patients rely only on medications and use a psychiatric illness to try to excuse bad behavior or "personality pathology." But it's also naive to think that all mental illness is treatable without medications (which I recognize is NOT what you're advocating). The issue becomes that anti-psychiatry often mixes with what I'll call "Psychiatric Deconstructionists," which inevitably leads to a questioning of everything bordering on solipsism. This lends to a popular lay idea that everything can be fixed with something like exercise, or vitamins, or nutritional changes, or behavioral therapy.

Penicillin wasn't discovered because we had an understanding of germ theory or beta-lactams, but by accident. We found it worked, and then developed the theory after. It's actually a common misunderstanding that we developed so many of our drugs because we have a sophisticated understanding of the disease process. Commonly (as with many psychiatric meds), we discover a beneficial effect, then develop the theory of disease from the effects of the medication (serotonin hypothesis of depression), then may develop further drugs based on the hypothesis. The first antidepressants were anti-tuberculosis meds that seemed to make everyone happier. Just because we don't know everything, or that DSM is only a step in the right direction (and much better than DSM-I) but not the last step, doesn't mean that medications don't have the effect we want them to have.

 

[splik]

splik :
wow thats convincing 😛 thanks mate and im reading fish right now, almost half way through but this is a descriptive book, im looking for a biological explanation ..

so what do you tell your patients ? that we are still clueless about their diseases ? wont that cost us their trust ?

you've missed the point somewhat. the reason why people suggest reading fish (again the Hamilton edition not the Casey and Kelly one) and other descriptive psychopathology texts is to introduce you to the descriptive tradition in psychiatry. This is very important because we need to have a very firm grasp of what we are describing if we are to come up with a meaningful explanation (biological or otherwise) and DSM-IV and to a lesser extent ICD-10 fail us somewhat in this regard. Which is to say that a biological explanation for a DSM-IV construct is more than useless; it is a fallacy.

What I tell my patient depends on their level of understanding and what they believe. I try and avoid biochemical discourses of depression because I believe this is what is feeding the chronicity of depression. In recent years actually the incidence of depression has been falling, but the prevalence has been increasing which suggests that whereas in the past people would get better, fewer people are today. The pharmaceutical companies have pushed a biochemical discourse of depression which disempowers people by undermining their own resources and instead privileges the biochemical notion that depression is caused by a chemical imbalance that is corrected by antidepressants. But if that is the case, does that mean that one needs to continue taking the antidepressants? Won't the depression return once you stop? etc.

I stop more antidepressants than I prescribe, but I still prescribe them because in some cases they help. I just think we need to be careful about the message that we send. Often they help because they provide a 'way out' for patients - like throwing them a lifeline. They can help with increasing energy, appetite, or sleep which in turn has other effects. Incidentally the most remarkable response to antidepressants I saw was a patient of mine with severe depression secondary to tetrabenazine (which is a VMAT inhibitor and thus depletes presynaptic catecholamines). So he had a depression where a 'biochemical' cause was primary. I gave him sertraline and a month later he was transformed! There could be no placebo effect because he did not know he was taking it.

Don't you think you would be more likely to lose the trust of your patients if you are dishonest? I don't often say 'I don't know what causes your problem and I don't know how the treatment helps' but when I do the patients find it extremely refreshing and often have suspected as much anyway! I tend to go with whatever patients find helpful. Some patients believe their illness was caused by sexual abuse etc. I work with it, because if it's helpful for them, it's helpful for me, and that is how you build rapport and thus trust.

There is a biological basis to all our thoughts, feelings, actions where defined as normal or 'abnormal'. Do not confuse correlation with causation.

 

[Ibid]

Yes, I think we could all do with less rubbing up

Depends who is doing the rubbing 🙂

It saddens me to see so many patients rely only on medications and use a psychiatric illness to try to excuse bad behavior or "personality pathology." But it's also naive to think that all mental illness is treatable without medications (which I recognize is NOT what you're advocating). The issue becomes that anti-psychiatry often mixes with what I'll call "Psychiatric Deconstructionists," which inevitably leads to a questioning of everything bordering on solipsism. This lends to a popular lay idea that everything can be fixed with something like exercise, or vitamins, or nutritional changes, or behavioral therapy.

.

I agree with everything you are saying. The state of the art is what it is and I'm as guilty as anyone for argueing the toss about just what this is and what it means. Those are undoubtedly interesting conversations but ultimatly as you allude and I agree they are red herrings.

I never met anyone who experiences psychotic episodes who doesn't want that particular mental distress to "go away".

I am as frustrated as anyone by people who won't take responsibility for themselves. However I do think that most people who experience psychosis are not approached in a way that would enable them to do so.
More often I see them tied up in knots and reaching unhelpful conclusions about choices they should make.

My contention is simply this:

The vast majority of people who experience psychosis but refuse medication would make a rational choice to take medication if that rational choice was based on an in depth exploration and conversation about what happens when they are psychotic, the sort of thoughts they have and what risks they run when they are psychotic. Patients do not and will not make a rational choice to take medication predicated on in depth discussions about pharmacology, neurology and such.

Why the vast majority of psychiatrists persist with the latter sorts of conversations (which tend to be rather stident) when clearly this approach fails again and again in practice mystifyies me. It matters not a bean if medication is the solution if people won't take it.

The conventional wisdom not to talk about the content of psychotic thought is a real barrier to the first sort of conversation which would, it is my contention, pay huge dividends.

 

[nitemagi]

The vast majority of people who experience psychosis but refuse medication would make a rational choice to take medication if that rational choice was based on an in depth exploration and conversation about what happens when they are psychotic, the sort of thoughts they have and what risks they run when they are psychotic. Patients do not and will not make a rational choice to take medication predicated on in depth discussions about pharmacology, neurology and such.

This presumes:
1. They have insight into their condition, and that it is abnormal. Not all do.
2. They have the ability to rationalize. Unfortunately due to the nature of the illness itself, the faculties for rationalizing accepting a medication can often only be restored by the medication itself.

Your premise is fine for other medication classes with relatively intact individuals. But true informed consent in a severely psychotic patient isn't always feasible. More often we make do with informed assent. Meaning we know they don't have the ability in their paranoid state to fully weigh the risks, benefits, and alternatives of a medication. But if they're willing to agree to the med nonetheless, then hopefully we can restore that ability.

Your argument is actually a good basis for other therapeutic interventions, such as videotaping a schizophrenic in their most psychotic state, say at the admission to a hospital. Many don't remember and don't believe just how severe they were. Showing them a video after they're linear again sometimes brings tremendous insight. Then this can be segwayed into a mental health advanced directive (they appoint a surrogate decision-maker when they're incapacitated, and/or make decisions as to how they'd want to be treated).

Ibid, how much exposure have you had with severely decompensated schizophrenics? Sometimes even getting basic biographical data from them can be near impossible. Do you really think having a rational conversation with them in such a state is realistic?

 

[nitemagi]

The conventional wisdom not to talk about the content of psychotic thought is a real barrier to the first sort of conversation which would, it is my contention, pay huge dividends.

I only bring up mechanisms of medications if a patient asks. Then I assess their level of education and try to give an appropriate explanation for them, the environment, and their state and situation.

While having thoughtful conversations about psychotic content is a nice idea for building a therapeutic alliance, again in a severely paranoid patient rationality can go out the window. I give 2 examples -- I have a patient I've seen for some time, we get along well, he gets psychotic and becomes paranoid that everything offered to him is poison. I come and offer him a medication and by my offering anything he presumes I am trying to poison him.

I had a medical student who studied "Logic" in undergrad and decided he wanted to see if he could apply Logic based techniques with a schizophrenic patients, believing in the Golden age of rationality somehow winning over the patients symptoms. He was a hair away from being assaulted. The patient couldn't engage in a rational dialogue, the student couldn't read basic body language, and he kept pushing an agenda that the patient couldn't tolerate.

 

[Ibid]

This presumes:
1. They have insight into their condition, and that it is abnormal. Not all do.
2. They have the ability to rationalize. Unfortunately due to the nature of the illness itself, the faculties for rationalizing accepting a medication can often only be restored by the medication itself.

Your premise is fine for other medication classes with relatively intact individuals. But true informed consent in a severely psychotic patient isn't always feasible. More often we make do with informed assent. Meaning we know they don't have the ability in their paranoid state to fully weigh the risks, benefits, and alternatives of a medication. But if they're willing to agree to the med nonetheless, then hopefully we can restore that ability.

My point concerns the periods of time between acute phases.

Your argument is actually a good basis for other therapeutic interventions, such as videotaping a schizophrenic in their most psychotic state, say at the admission to a hospital. Many don't remember and don't believe just how severe they were. Showing them a video after they're linear again sometimes brings tremendous insight. Then this can be segwayed into a mental health advanced directive (they appoint a surrogate decision-maker when they're incapacitated, and/or make decisions as to how they'd want to be treated).

That is really interesting. I do have to say I'm sceptical about the majority of people really not remembering the content of thier psychosis but I can understand why if someone was engaged in a battle of wills about the rights and wrongs of long term medication they might give this impression.

Every single person I have ever spoken with about the content of their psychosis has just been very upfront about it. I have never had someone tell me "I can't remember". (I am not talking about people with a forensic history).

Ibid, how much exposure have you had with severely decompensated schizophrenics? Sometimes even getting basic biographical data from them can be near impossible. Do you really think having a rational conversation with them in such a state is realistic?

Substantial and again I'm not suggesting you could have that sort of conversation with someone during the acute phase. What you are saying is really interesting but while I take no offense I perhaps am not quite as green to these issues as you appear to be thinking.

I can see why you might think I had very little exposure as it would explain why I appear to have such a contary view point. I just see and interpret things a little differently that is all.

 

[Ibid]

I had a medical student who studied "Logic" in undergrad and decided he wanted to see if he could apply Logic based techniques with a schizophrenic patients, believing in the Golden age of rationality somehow winning over the patients symptoms. He was a hair away from being assaulted. The patient couldn't engage in a rational dialogue, the student couldn't read basic body language, and he kept pushing an agenda that the patient couldn't tolerate.

I'm not surprised, this approach is going to win you a knuckle sandwhich from just about anyone rational or not.

What is a pity is that this "logical" approach is more the rule than an experiment, certainly in most inpatient settings. I see "logical" staff essentially winding up perfectly rational patients until they do lose control and up being sedated. Or more truthfully being punished.

What I really see all the time is a confusion between insight and an alternate point of view. (a point probably more relevant to my above post)

 

[nitemagi]

My point concerns the periods of time between acute phases.

But you're critiquing med consents in emergency room situations?

Ibid, you make sweeping statements about the rule vs. not. According to whom? Can you give citations to this. Or is this based on personal experience? How many psychotic patients have you talked to? Seen by how many different psychiatrists?

 

[nitemagi]

Every single person I have ever spoken with about the content of their psychosis has just been very upfront about it. I have never had someone tell me "I can't remember". (I am not talking about people with a forensic history).

It's different between total amnesia of an event and full vivid recall with perspective as to the degree of recall of how out of touch they were. More often I hear "yeah I was pretty out of it," not really recognizing all the levels to that. After a video presentation I hear "I knew I was bad, I didn't realize I was that bad."

 

[Ibid]

Ibid, you make sweeping statements about the rule vs. not. According to whom? Can you give citations to this. Or is this based on personal experience? How many psychotic patients have you talked to? Seen by how many different psychiatrists?

I ll edit in an answer to this.

EDIT: Yes, I have made some generalizations but that is just what they are. I don't content that a generalzation would be true in every case. How many? Countless. I thought about this a lot today. The question I kept asking myself was "how many dead people have you forgotten Ibid?" A patch work of images kept comming to mind. People I knew detail of their lives, laughed at their jokes, knew their voice on the phone, now I can't remember their names. I see dangling feet, twisted faces, burn't bodies, blood spatterd walls and I can't remember who they were anymore and again I wonder how many have I forgotten. Sorry not much of an answer for you. Best I can do right now.

It's different between total amnesia of an event and full vivid recall with perspective as to the degree of recall of how out of touch they were. More often I hear "yeah I was pretty out of it," not really recognizing all the levels to that. After a video presentation I hear "I knew I was bad, I didn't realize I was that bad."

I can certainly see the utility of this. I still think that "yeah I was pretty out of it" is more about a lack of awareness about presentation, rather than psychotic content and remembering that.

I don't need to tell you the sort of complexities that impinge on a relationship where one party can detain the other of their liberty.

I maintain that people who have been psychotic and especially if they have had that experience more than once, are fairly uniformly cognisant of the subtle shades that exist between rationality and florid psychosis and just what those shaded "feel" like.

Even with this understanding, what does often go with this is a naivety about the psychiatrists understanding, with a tendency to underestimate the level of understanding their psychiatrist might have about a subjective experience that won't have experienced themselves.

It's a complex picture thats for sure.

 

[Salpingo]

In recent years actually the incidence of depression has been falling, but the prevalence has been increasing which suggests that whereas in the past people would get better, fewer people are today. The pharmaceutical companies have pushed a biochemical discourse of depression which disempowers people by undermining their own resources and instead privileges the biochemical notion that depression is caused by a chemical imbalance that is corrected by antidepressants. But if that is the case, does that mean that one needs to continue taking the antidepressants? Won't the depression return once you stop? etc.

That's a pretty powerful conclusion to make. I'd be very interested to see the data. Theoretically, if depression was gradually being made at a younger ages, wouldn't that increase prevalence of the disease without changing incidence? What if the lifespan of depressed patients was increasing due to improved treatment (not necessarily due to suicide, since that rate has remained stagnant, but better maintenance of health)?

Also, how is prevalence counted? If a patient is lost to follow up, are they considered "cured"? Perhaps, in the past, people sought help only once or twice before giving up, and now are more persistent.

 

[nitemagi]

I don't need to tell you the sort of complexities that impinge on a relationship where one party can detain the other of their liberty.

Sure, but that's a totally different issue than informed consent for medication and degree of memory of psychotic thought content.

I maintain that people who have been psychotic and especially if they have had that experience more than once, are fairly uniformly cognisant of the subtle shades that exist between rationality and florid psychosis and just what those shaded "feel" like.

Even with this understanding, what does often go with this is a naivety about the psychiatrists understanding, with a tendency to underestimate the level of understanding their psychiatrist might have about a subjective experience that won't have experienced themselves.

While it's true that most psychiatrists have never been psychotic themselves, your belief that those who have been psychotic recognize the subtle shades between rationality and psychosis is simplistic and a bit too rosy colored for the real world. I'm sure there are some individuals aware, but it is most definitely NOT the majority and not a uniform characteristic as you claim. That's the real nature of actual psychotic symptoms - they cannot be discerned from reality for the individual. So when it comes on they can't discern it from reality.

Ibid your thoughts on psychosis, to use a common legal objection from TV, "assume facts not in evidence." A humanistic approach is most definitely the way to go in treating all patients and many with a psychotic history get relegated by all of society to second-class treatment, but that mistreatment by all of society doesn't bestow capacities on an individual that circumvents the nature of the illness itself.

 

[splik]

That's a pretty powerful conclusion to make. I'd be very interested to see the data. Theoretically, if depression was gradually being made at a younger ages, wouldn't that increase prevalence of the disease without changing incidence? What if the lifespan of depressed patients was increasing due to improved treatment (not necessarily due to suicide, since that rate has remained stagnant, but better maintenance of health)?

Also, how is prevalence counted? If a patient is lost to follow up, are they considered "cured"? Perhaps, in the past, people sought help only once or twice before giving up, and now are more persistent.

This was from the National Comorbidity Survey- the two papers that consider the data I have cited are the 2 most cited papers in the history of psychiatry. Have a look and you will see why none of your alternative explanations are relevant and even if they were would still support my contention. There is no doubt that our concept of depressive illness has transformed into what was once most a self-limiting illness into a recurrent illness for which 1 in 7 patients never recover from the index episode. Now my explanation of why that is may be wrong, and is certainly oversimplistic, but we now put people on antidepressants for life whereas these antidepressants would have been discontinued in the past.

 

[Ibid]

Sure, but that's a totally different issue than informed consent for medication and degree of memory of psychotic thought content.

I think we have somehow ended up talking at cross purposes on this point. I don't think we disagree about consent issues and insight when people are psychotic.

While it's true that most psychiatrists have never been psychotic themselves, your belief that those who have been psychotic recognize the subtle shades between rationality and psychosis is simplistic and a bit too rosy colored for the real world.

Not at all simplistic imo. What I do see all the time, that is simplistic, is disagreement badged as lack of insight for convenience. And shockingly unethical it is as well imo. That is the real world that people experience all the time.

I'm sure there are some individuals aware, but it is most definitely NOT the majority and not a uniform characteristic as you claim.

This is where we differ.

Ibid your thoughts on psychosis, to use a common legal objection from TV, "assume facts not in evidence."

And if you were being fair, while it is your opinion and widely shared in my experience, your use of "definitely not" opens you to the same charge.

That's the real nature of actual psychotic symptoms - they cannot be discerned from reality for the individual. So when it comes on they can't discern it from reality.

Your use of the phrase "so when it comes on they can't discern it from reality" really concedes my point. The corollary of this is "before it comes on they are completely able to discern the difference between psychotic thoughts from reality."

Basically what you have written above is saying you agree with me but you would like to continue to contend that you don't anyway.

I would also contend that the "when it comes on process" is a well understood phenomenom by people who experience psychosis and that is why training people in self monitoring their own relapse signatures works for so many people. This is well research and goes some whay to afford evidence that I am much closer to the truth than you impute. (apart from when you seem to concede by default that I am right as above.)

Either we are talking at cross purposes again or their is a contradiction in what you are saying that make me correct.

 

[nitemagi]

Basically what you have written above is saying you agree with me but you would like to continue to contend that you don't anyway.

Um, no. I stated that your points about speaking humanistically is fair, but your points about insight and memory are inaccurate. I'm open to evidence to disprove this though. I've just seen way too many patients with too little memory, perspective, and insight on their condition. How much time have you spent on inpatient psychiatric units?

This is well research and goes some whay to afford evidence that I am much closer to the truth than you impute. (apart from when you seem to concede by default that I am right as above.)

Care to cite the actual studies for this "well research" area?

 

[Ibid]

Um, no. I stated that your points about speaking humanistically is fair, but your points about insight and memory are inaccurate. I'm open to evidence to disprove this though. I've just seen way too many patients with too little memory, perspective, and illness on their condition. How much time have you spent on inpatient psychiatric units?



Care to cite the actual studies for this "well research" area?

Well, yes, I am open to evidence as well but as I pointed out above you seem to implicitly agree with me anyway with your use of the phrase "when it comes on". I don't see how you are resolving this contradiction to yourself.

I agree with you to the extent that people who experience psychosis would do well to be more upfront about their experience and take more responsibility and certainly to think more about the risks that they run when they become psychotic.

However I still contend that the conflation of disagreement with lack of insight is a real barrier to patients taking on that responsibity for themselves in conjuntion with their doctor. The definition of a good theraputic alliance is not just a patient who does everything the doctor suggests without question.

Your last question? Bleedin 'ell....I'll give you a hint. I don't work in Burger King.

I'll look for some studies on relapse signature monitoring.

 

[nitemagi]

Well, yes, I am open to evidence as well but as I pointed out above you seem to implicitly agree with me anyway with your use of the phrase "when it comes on". I don't see how you are resolving this contradiction to yourself.

Quite easily, actually. The idea of insight when completely asymptomatic but no insight when symptoms begin means the insight is superficial or non-existent. If they know those shades of psychosis so well they'd recognize when it's coming on, and most of the time they don't. Therefore the insight is more likely lip service insight as opposed to in-depth insight.

And don't get all uppity about my questioning your degree of clinical exposure. Most people on sdn list their level of training. If they don't, then that's a bit of a red flag and IMHO is a perfectly good reason to be questioned, especially when that individual is giving strong opinions without independent evidence to back it up.

If you're a physician or work in multiple treatment environments, that's one thing, meaning you've seen people at multiple levels of functioning. If you work on an inpatient unit there's a selection bias of primarily seeing the refractory or decompensated individuals only. If you're working in an outpatient environment only, though, you're only seeing individuals when they're relatively intact.

Many people in the outpatient world say they recognize their illness and the need for their medication. But their repeated admissions and poor adherence speaks against that. This isn't to blame patients, but just a consequence of the illness itself and of being human (there's a massive ego blow to admitting you have an illness like schizophrenia).

 

[Ibid]

Quite easily, actually. The idea of insight when completely asymptomatic but no insight when symptoms begin means the insight is superficial or non-existent. If they know those shades of psychosis so well they'd recognize when it's coming on, and most of the time they don't.

The first point is just supposition. The second is just an arguement for relaspse signature monitoring training.

And don't get all uppity about my questioning your degree of clinical exposure. Most people on sdn list their level of training. If they don't, then that's a bit of a red flag and IMHO is a perfectly good reason to be questioned, especially when that individual is giving strong opinions without independent evidence to back it up.

Well I apologise if I came across that way. I didn't intend to.

I have been asked personal questions before on this board and in quite an indecorus fashion I must say, unlike your good self. My personal circumstances are irrelvant and I make it a rule not to post personal information. So Flag shmag whatever.....again I have accepted that the point of view I am expressing is unorthodox and I am just stating it clearly and I think without being intentionally inflamitory. And I have to say so far you have not quoted a paper to back up your suggestions either. I will say that I appreciate your thoughtful answers and I have every respect for what you are saying though. Posts that are just full of links to pub med could be rather tedious in anycase.

Anyway back to the point at hand, I have found quite a good paper on relapse signature monitoring.

EDIT: Schizophrenia: early warning signs

http://apt.rcpsych.org/content/6/2.toc


I don't suggest it's going to change your mind but in anycase I think it points in the direction of my arguement.