Stupid DSM V questions

[nancysinatra]

Ok so the DSM V is coming out and there are some changes. I am just about to finish residency having learned the DSMIV.

Does anyone else want to know--if what we've been taught these past 4 years is now being "replaced," then what did we learn? And did we potentially harm any patients along the way by espousing an incorrect diagnostic system? Remember there was a time when we blamed refrigerator mothers and "diagnosed homosexuality"...

Especially with Axis II. I have been taught to diagnose a lot of Axis II stuff. Was it inaccurate? (And I know people will say the new DSM is a "clarification" or other such euphemism. I still want to know--did we misdiagnose people with the DSMIV?)

Can patients rightfully come to us and say we misled them? I mean, I was on the DSM IV bandwagon these past four years. I probably told patients they had conditions that according to the new DSM, they actually don't have. Or I told them they were fine, when in fact they're gravely ill. So what does that say about our training, and our work? Is it just a work in progress? Is that good enough for modern medicine?

And ok here's another really stupid question. It will betray my jaded-ness, but so be it. Modern homo sapiens has existed for what, 50,000 years? Why is it that in the last 60 of those years, there has been a need for 5 DIFFERENT DSMs??? Does anyone seriously believe that either human nature has changed that much or that so many new (and increasingly correct!) ideas have sprung up in those 60 years that we are really truly looking at a groundbreaking achievement with the DSMV?

If the DSM were some astronomical guide with improvements in optical science behind its changes, I'd understand. But to be honest, I don't know what guides the diagnostic changes in our field.

I feel like one day, all the DSMs will be looked back upon sort of like the modern-day equivalent medieval papal encyclicals. I just don't know who to believe in with this new thing coming out...

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[MacDonaldTriad]

Relax, 50,000 years of neuroses hasn't changed much. The changes will be focused on the parts that have not gone well with validity. A lot of this is addiction, some child stuff, and the 5 axes. Things will look the same in the long run. Mood disorders and psychosis are not radically different. The boards are not moving to DSM-5 (that is right DSM-V is now not correct), until 2017.

 

[nancysinatra]

Relax, 50,000 years of neuroses hasn't changed much. The changes will be focused on the parts that have not gone well with validity. A lot of this is addiction, some child stuff, and the 5 axes. Things will look the same in the long run. Mood disorders and psychosis are not radically different. The boards are not moving to DSM-5 (that is right DSM-V is now not correct), until 2017.

Well it's the 5 Axis thing that gets me. I find it hard to look a patient in the face and tell them they have some personality disorder when I know that in 15 years the criteria will change and they will no longer have the PD. Oh so conveniently it always manages to fit the times.

And I really don't get why, if these problems have been around since the dawn of time, why only now, NOW, during my lifetime, we are so fortunate to witness the arrival of DSM-5 (or DSM-FIVE)? (It's like just "happening" to be alive during the Council of Trent.) There are many sciences that predate ours and you'd think, if DSM-5 were onto something, it might have been realized earlier. It's not that hard to "validate" a mental health concept... The statistics can't be that difficult. And seriously, do advances in statistics drive our field?

Galileo figured out that the earth revolves around the sun 450 years ago but only now we are understanding "bereavement" properly? And only now do we have the intelligence to rename dementia for what it is, a "neurocognitive disorder"?

 

[billypilgrim37]

Ok so the DSM V is coming out and there are some changes. I am just about to finish residency having learned the DSMIV.

Don't panic, and always carry a towel.

Does anyone else want to know--if what we've been taught these past 4 years is now being "replaced," then what did we learn?

98% of DSM5

And did we potentially harm any patients along the way by espousing an incorrect diagnostic system?

Don't give the malpractice attorneys any ideas. If anything, we destroyed the metabolic profiles of many children with atypicals by diagnosing them with non-episodic bipolar disorder, but the DSM didn't change for that to happen. A patient's suffering is mostly independent of what we call it. Mostly.

Remember there was a time when we blamed refrigerator mothers and "diagnosed homosexuality"...

Right, and we still tell people there are "chemical imbalances." Like a deodorant commercial. "Pristiq: NorepinePHrine-balanced for a man, but serotonergic enough for a woman." Just Pfizer now instead of Procter and Gamble.

Especially with Axis II. I have been taught to diagnose a lot of Axis II stuff. Was it inaccurate? (And I know people will say the new DSM is a "clarification" or other such euphemism. I still want to know--did we misdiagnose people with the DSMIV?)

Well, of course, as much as you can misdiagnose someone with a diagnosis that has so little validity. Many of the personality disorders have very little validity, and whether they are in the book or not is more political than scientific. That doesn't change in DSM5. And how often does someone with just a PD come to a psychiatrist's attention? Usually if they are seeing us there's a rip-roaring Axis 1 going along with it, and if there is, we're probably getting the PD diagnosis wrong anyway.

Can patients rightfully come to us and say we misled them? I mean, I was on the DSM IV bandwagon these past four years. I probably told patients they had conditions that according to the new DSM, they actually don't have.

Not likely. For the most part, DSM5 expands criteria, not conflates. This is a good thing in that it will allow people who are suffering to still be able to receive services despite not meeting arbitrary numbers of criteria. This is also a good thing because people don't become ill because they otherwise meet criteria for a diagnosis without being ill. People will say this is a bad thing because they don't understand how the world works. If we relaxed the duration criteria for hypomania, nobody would show up and say, "Hi Doc! Used to, I wouldn't come see you because my hypomanic episodes only lasted for 3.9 days each time, but now that the DSM6 says it only takes 3 days to be hypomanic, I want my Seroquel!" It never worked that way, and no DSM will change it. People come to you because they are sick and want help. Not because they meet do or do not meet criteria for a disorder.

Or I told them they were fine, when in fact they're gravely ill.

I think most of us ask ourselves how sick someone is first and then work our way backwards. You probably do that too.

So what does that say about our training, and our work? Is it just a work in progress? Is that good enough for modern medicine?

It's so good that the psychologists want in on our action!

And ok here's another really stupid question. It will betray my jaded-ness, but so be it. Modern homo sapiens has existed for what, 50,000 years? Why is it that in the last 60 of those years, there has been a need for 5 DIFFERENT DSMs??? Does anyone seriously believe that either human nature has changed that much or that so many new (and increasingly correct!) ideas have sprung up in those 60 years that we are really truly looking at a groundbreaking achievement with the DSMV?

We've also had 5 game of thrones novels. There were actually 14 wizard of oz books before l frank baum died and some woman wrote like 30 more. Heck, tolkien wrote six books just for LOTR, though they were stuck together to be sold as 3. And we still don't know what order we're supposed to read the Narnia books.

I think you can make an argument that there have been two DSMs and a bunch of tiny little revisions of minimal consequence. The first two were a bunch of adjustment reactions, and the last 3 have been people playing with the Wash U research criteria. There have been like 10 ICDs, so we got nothing on the Eurotrash (sorry splik). Besides, do you know how many revisions the mormon bible has had in that same time? And 49% of the country wanted a Mormon for president last time around! Even if Jeff Lieberman didn't just fall and break a bunch of bones, I don't think he would get so many votes if he ran for POTUS.

If the DSM were some astronomical guide with improvements in optical science behind its changes, I'd understand. But to be honest, I don't know what guides the diagnostic changes in our field.

It's like the US News rankings. They have to change the formula every few years to make it look like med schools are actually changing. That's why Stanford goes back and forth from being like number 4 to number 14 (when they change whether they use total research dollars or research dollars PER FACULTY). It ain't because Palo Alto got smarter or dumber.

That said, the DSM5 committees worked really hard. They published white paper after white paper. They explained their rationales ad nauseam ad infinitem ad lib. You don't know how it happened because it's incredibly boring and you don't need to know. If you needed to know, you would have learned. The best science is sometimes kinda lousy, but we have to spend those nimh dollars somewhere, and some of those dollars produce data that inform very smart people, some of whom have been bought out by pharma, about tiny little changes that make a lot of sense.

Since the science is incomplete, sometimes we just check to see whether the old system mattered. Autism spectrum syndrome? We didn't know that our previous subtypes were going to have zero prognostic consequences. It was reasonable to think that Aspies were fundamentally different from autistics, even if they weren't, if you control for how well functioning they are. It was also reasonable to think that it would matter if someone abused or was addicted to drugs, but turns out, it doesn't. Who knew?

Put it this way, the science supporting the revisions in the DSM5 is much more reliable than the info that we used to invade Iraq. And while Latuda is expensive, it's not as expensive as writing new scripts for Kathryn Bigelow.

I feel like one day, all the DSMs will be looked back upon sort of like the modern-day equivalent medieval papal encyclicals. I just don't know who to believe in with this new thing coming out...

If the world lasts that long, it will only be because we did our jobs very well.

 

[vistaril]

Ok so the DSM V is coming out and there are some changes. I am just about to finish residency having learned the DSMIV.

Does anyone else want to know--if what we've been taught these past 4 years is now being "replaced," then what did we learn? And did we potentially harm any patients along the way by espousing an incorrect diagnostic system? Remember there was a time when we blamed refrigerator mothers and "diagnosed homosexuality"...

Especially with Axis II. I have been taught to diagnose a lot of Axis II stuff. Was it inaccurate? (And I know people will say the new DSM is a "clarification" or other such euphemism. I still want to know--did we misdiagnose people with the DSMIV?)

Can patients rightfully come to us and say we misled them? I mean, I was on the DSM IV bandwagon these past four years. I probably told patients they had conditions that according to the new DSM, they actually don't have. Or I told them they were fine, when in fact they're gravely ill. So what does that say about our training, and our work? Is it just a work in progress? Is that good enough for modern medicine?

And ok here's another really stupid question. It will betray my jaded-ness, but so be it. Modern homo sapiens has existed for what, 50,000 years? Why is it that in the last 60 of those years, there has been a need for 5 DIFFERENT DSMs??? Does anyone seriously believe that either human nature has changed that much or that so many new (and increasingly correct!) ideas have sprung up in those 60 years that we are really truly looking at a groundbreaking achievement with the DSMV?

If the DSM were some astronomical guide with improvements in optical science behind its changes, I'd understand. But to be honest, I don't know what guides the diagnostic changes in our field.

I feel like one day, all the DSMs will be looked back upon sort of like the modern-day equivalent medieval papal encyclicals. I just don't know who to believe in with this new thing coming out...

I think the idea of a dsm is actually one of the more troubling and irritating aspects of our field.

even more troubling, the existence of the dsm forces people(in some cases) to use language and speak diagnostically in ways that are useless and don't convey anything of value.

 

[birchswing]

Ok so the DSM V is coming out and there are some changes. I am just about to finish residency having learned the DSMIV.

Does anyone else want to know--if what we've been taught these past 4 years is now being "replaced," then what did we learn? And did we potentially harm any patients along the way by espousing an incorrect diagnostic system? Remember there was a time when we blamed refrigerator mothers and "diagnosed homosexuality"...

Especially with Axis II. I have been taught to diagnose a lot of Axis II stuff. Was it inaccurate? (And I know people will say the new DSM is a "clarification" or other such euphemism. I still want to know--did we misdiagnose people with the DSMIV?)

Can patients rightfully come to us and say we misled them? I mean, I was on the DSM IV bandwagon these past four years. I probably told patients they had conditions that according to the new DSM, they actually don't have. Or I told them they were fine, when in fact they're gravely ill. So what does that say about our training, and our work? Is it just a work in progress? Is that good enough for modern medicine?

And ok here's another really stupid question. It will betray my jaded-ness, but so be it. Modern homo sapiens has existed for what, 50,000 years? Why is it that in the last 60 of those years, there has been a need for 5 DIFFERENT DSMs??? Does anyone seriously believe that either human nature has changed that much or that so many new (and increasingly correct!) ideas have sprung up in those 60 years that we are really truly looking at a groundbreaking achievement with the DSMV?

If the DSM were some astronomical guide with improvements in optical science behind its changes, I'd understand. But to be honest, I don't know what guides the diagnostic changes in our field.

I feel like one day, all the DSMs will be looked back upon sort of like the modern-day equivalent medieval papal encyclicals. I just don't know who to believe in with this new thing coming out...

There must be a sociological component to this. I remember Mark Twain writing about having neurosthenia. You don't hear much about that anymore. And of course women were diagnosed with things like hysteria.

But the part that is so interesting to me is that not only the names were different but also the presenting symptoms. My therapist told me that a long time ago people with anxiety used to have their hands go numb. Why would that have changed? Was there really somehow a collective, societal response to stress? It's true with sexuality, too. The things people find attractive change over time. And I guess that is somehow socially constructed. Hard to get one's head around.

 

[Armadillos]

Might be a somewhat niave way for me to look at things, but I dont think it really matters at all if things like certain personality disorders actually "exist" in the metaphysical sense. Seems like the whole point of the DSM is just to provide a common vocabulary for research reasons and for clinicians to communicate with each other about patients with similar groups of symptoms.

I feel like both the super pro DSM folks and the super anti-DSM V folks are trying to make the DSM mean more than it actually does.

 

[vistaril]

Well, of course, as much as you can misdiagnose someone with a diagnosis that has so little validity. Many of the personality disorders have very little validity, and whether they are in the book or not is more political than scientific. That doesn't change in DSM5. And how often does someone with just a PD come to a psychiatrist's attention? Usually if they are seeing us there's a rip-roaring Axis 1 going along with it, and if there is, we're probably getting the PD diagnosis wrong anyway.
.

I'm not all that interested in what it is called.....but I think most of us see a lot of patients with character pathology to the extent that it is the dominating force.

3/4ths of BPD patients met criteria at some point in their life for a mood d/o, but that alone doesn't really mean a lot to me.

 

[vistaril]

Might be a somewhat niave way for me to look at things, but I dont think it really matters at all if things like certain personality disorders actually "exist" in the metaphysical sense. Seems like the whole point of the DSM is just to provide a common vocabulary for research reasons and for clinicians to communicate with each other about patients with similar groups of symptoms.

I feel like both the super pro DSM folks and the super anti-DSM V folks are trying to make the DSM mean more than it actually does.

we wouldn't need the dsm to 'communicate' with other clinicians though.....non-dsm language is usually better anyways.


the worst thing about the dsm isn't this but that it's very existence hurts the credibility of psychiatry though. We can say "oh it doesn't really matter to individual decisions for patients" all we want, but what the public(and medicine as a whole) sees is a diagnostic book that was created by a bunch of academics in hotel conference rooms arguing with each other.

 

[billypilgrim37]

I'm not all that interested in what it is called.....but I think most of us see a lot of patients with character pathology to the extent that it is the dominating force.

3/4ths of BPD patients met criteria at some point in their life for a mood d/o, but that alone doesn't really mean a lot to me.

Sure. It's clear that we know so little about BPD that it's not funny. Given that our presented options for conceptualization are a) pure character pathology/moral failing, or b) variant of bipolar disorder, it's no wonder we all just throw up our hands. NIMH has good ideas on these matters, but our grandchildren will be dead before they come up with something clinically useful. We will all be speaking that Chinese-English mash-up from Firefly by then (or at least our great great great great 孙子 will).

 

[billypilgrim37]

We can say "oh it doesn't really matter to individual decisions for patients" all we want, but what the public(and medicine as a whole) sees is a diagnostic book that was created by a bunch of academics in hotel conference rooms arguing with each other.

The folks who care enough about the DSM to know how it was made are the same people who pretend like they read Foucault. If we didn't have it, they would criticize us for that too!

It's the general fallacy of all conservative policymaking (liberals just have DIFFERENT fallacies, not lesser ones):
"This thing we have is bad! We should get rid of it!"
"But wasn't it bad before too?"
"Yeah, but..."

For example,
"Unions are bad! We should get rid of them!"
"Weren't labor conditions in the late 19th century absolutely deplorable, and labor unions are to credit for much of the gains in worker's rights through the 20th century?"
"Yeah, but unions are bad! Get rid of them!"

Or
"The DSM is bad! We should get rid of it!"
"But wasn't psychiatry before just a mish mash of people saying you had schizophrenia because you saw your mom blowing the milk man in the walk-in freezer?"
"Yeah, but it's bad! We should get rid of it!"

 

[vistaril]

Or
"The DSM is bad! We should get rid of it!"
"But wasn't psychiatry before just a mish mash of people saying you had schizophrenia because you saw your mom blowing the milk man in the walk-in freezer?"
"Yeah, but it's bad! We should get rid of it!"

why do we have to have a disease called schizophrenia though?
My idea would be to strip it all away.....there has to be a better system. Surely there are some reasonable people out there who could figure one out.

 

[F0nzie]

why do we have to have a disease called schizophrenia though?
My idea would be to strip it all away.....there has to be a better system. Surely there are some reasonable people out there who could figure one out.

http://en.wikipedia.org/wiki/Integration_disorder

 

[billypilgrim37]

why do we have to have a disease called schizophrenia though?
My idea would be to strip it all away.....there has to be a better system. Surely there are some reasonable people out there who could figure one out.

Having a disease called schizophrenia doesn't have much to do with the DSM. If the DSM had never been written, we would still probably have diagnoses of schizophrenia, bipolar disorder, depression, autism, etc. We largely DID have those diagnoses before DSM.

*Cue dissertation from splik on pre-Freudian nosology*

 

[splik]

I think you can make an argument that there have been two DSMs and a bunch of tiny little revisions of minimal consequence. The first two were a bunch of adjustment reactions, and the last 3 have been people playing with the Wash U research criteria. There have been like 10 ICDs, so we got nothing on the Eurotrash (sorry splik).

But there have been so far 6 editions of the DSM (including DSM-III-R and DSM-IV-TR) and only 5 editions of the ICD (ICD 6 onwards) have had sections including mental and behavioral disorders. The ICD-6, published in 1948 was influenced by the US military in their classification of mental disorders. The other difference is that DSM-III onwards has been abused in defining how we diagnose mental disorders in clinical practice which was not its purpose. It was never meant to be a substitute for clinical experience but made it look like anyonecould make a diagnosis with a checklist. In contrast the ICD-9 and ICD-10 did not describe operational criteria for mental disorders. The DCR (for research) does do so but this is different as it is for research purposes.

The important of the DSM has far been overstated. It amazes me that so many psychiatrists don't realize that the ICD is the official classification system even in the US and CMS do NOT recognize DSM codes or diagnoses for billing. Everything has to translated in the bastardized americanised ICD codes. Similarly MOST insurance companies do not recognize DSM diagnoses. and the reality is most people do not use the DSM to make diagnoses anyway so any changes are more academic and have little bearing on how psychiatry is actually practiced. The DSM-5 is important because of its irrelevance. The inclusion of TDDD despite the evidence of its lack of utility and validity is the final nail in the coffin.

 

[billypilgrim37]

The inclusion of TDDD despite the evidence of its lack of utility and validity is the final nail in the coffin.

Problems with Dmdd was the topic of my grand rounds a few months ago.

Sent from my DROID RAZR using SDN Mobile

 

[DebDynamite]

we wouldn't need the dsm to 'communicate' with other clinicians though.....non-dsm language is usually better anyways.


the worst thing about the dsm isn't this but that it's very existence hurts the credibility of psychiatry though. We can say "oh it doesn't really matter to individual decisions for patients" all we want, but what the public(and medicine as a whole) sees is a diagnostic book that was created by a bunch of academics in hotel conference rooms arguing with each other.

Ah, the DSM.
When the finger points to the moon, the imbecile looks to the finger.

 

[F0nzie]

Problems with Dmdd was the topic of my grand rounds a few months ago.

I don't see why we can't just say: "Your kid is angry. Therapy for everyone". If the goal is to reduce over-diagnosis of childhood bipolar disorder, then stop training idiots.

 

[billypilgrim37]

If the goal is to reduce over-diagnosis of childhood bipolar disorder, then stop training idiots.

But then who will take care of all the adults?

 

[F0nzie]

But then who will take care of all the adults?

Send them my way.

*I am not accepting insurance at this time. Patients may submit a super bill to their insurance company for services rendered.*

 

[kugel]

I really do not understand all the fuss.
Which probably means I don't understand the situation.

But here's my take:
- There have been advances in diagnostic validity/reliability. If there weren't, it'd be a pretty sorry field.
- DSM is intended to be a work in progress, and so there are going to be revisions. Isn't that a good thing?
- Other fields go through similar changes, but they tend to happen piece-meal, for one disorder at a time, rather than to the whole field at once, and they tend to be released by competing sub-specialty panels and organizing boards - letting history sort out which scheme we think is "right" until the next advance. This means that the diagnostic scheme and criteria are often in flux and not fully accepted by practitioners - and patients/payors/colleagues often have no idea which criteria a practitioner was using at the time, e.g. The numbers used to diagnose diabetes and hypercholesterolemia.
- More and more illnesses are being defined by "elevated risk of later morbidity," so it really should have come as no surprise that psychiatry was going to try to folllow suit (re: risk of developing a psychotic disorder). I'm glad there was a discussion about this, but why no discussion about it in other fields?
(If I have the diseases of hypercholesterolemia and hypertension, what are my symptoms? We changed the practice of medicine from treating diseases to treating risk of diseases, but never had a discussion about whether that was a valid change.)
- The intended changes were put up for public comment and that comment process effected the outcome to some degree. Which other medical field has done that with its entire diagnostic scheme?
- The DSM process is heavily influenced by a group of "thought leaders," which will always make it somewhat suspect. And that is different from what other fields of human endeavor?
- The "thought leaders" are influenced to greater and lesser degrees by money and power. It has always been so.

Psychiatry could have presumed that the writings of our leaders are correct and immutable for all time, but wouldn't that make it a religion?

I read a FB post the other day that is paraphrased as, "If you don't want to be criticized; say nothing, do nothing, accomplish nothing."

It is a work in progress, and some revisions will turn out to be viewed in hindsight as more correct than others.

 

[Salpingo]

Don't panic, and always carry a towel.

QTF

Not likely. For the most part, DSM5 expands criteria, not conflates. This is a good thing in that it will allow people who are suffering to still be able to receive services despite not meeting arbitrary numbers of criteria. This is also a good thing because people don't become ill because they otherwise meet criteria for a diagnosis without being ill. People will say this is a bad thing because they don't understand how the world works. If we relaxed the duration criteria for hypomania, nobody would show up and say, "Hi Doc! Used to, I wouldn't come see you because my hypomanic episodes only lasted for 3.9 days each time, but now that the DSM6 says it only takes 3 days to be hypomanic, I want my Seroquel!" It never worked that way, and no DSM will change it. People come to you because they are sick and want help. Not because they meet do or do not meet criteria for a disorder.

I think this is the most dangerous part of DSM5.

1. It plays into the stereotype that psychiatrists/big pharma are trying to make it harder and harder to be "normal". Already, people are up in arms about the number of ADHD diagnoses. And now we're widening the net, using information gleaned at university hospitals with no idea what the ramifications are going to be in the actual community where the majority of psychiatry is practiced. Do we have real treatments for these people, or are we throwing more people into a diagnostic blender spiked with atypical antipsychotics?
2. Getting people hooked up with services can feed a self-perpetuating positive feedback loop. Example: you expand the diagnosis of autism. More kids get services for autism. More money is invested in research to keep up with this huge demand, resources are invested into autism support. This research brings more people into the fold as their kids are suffering. Then someone slams on the brakes, says wait, maybe we over-diagnosed this disorder. Too late, there's a huge lobby now dependent on the services you provided them, who will raise hell for even thinking about redefining their illness.

That said, the DSM5 committees worked really hard. They published white paper after white paper. They explained their rationales ad nauseam ad infinitem ad lib. You don't know how it happened because it's incredibly boring and you don't need to know. If you needed to know, you would have learned. The best science is sometimes kinda lousy, but we have to spend those nimh dollars somewhere, and some of those dollars produce data that inform very smart people, some of whom have been bought out by pharma, about tiny little changes that make a lot of sense.

I'm sure the DSM5 committees worked hard. I'm also sure there are committees on Capitol Hill that work hard. I also feel that Congress's current approval rating of -37% is very well earned. It seems that psychiatry has always accepted some degree of "lousy science" and did whatever the brilliant elders in the field said. Because, lets face it, research is incredibly boring. I guess, to be fair, its a field that attracts hippy humanists, not type-A empiricists, so we're never going to be like cardiologists or oncologists or surgeons who question lousy science on a daily basis. But if thats the case, it makes sense that people have become so pessimistic about the field.

Best case scenario, the DSM5 comes out, people realize its pointless but looks nice on a bookshelf, and we can get back to treating real illness and not flimsy diagnoses.

 

[Salpingo]

Also, as proof this isn't too complicated or boring to try to understand, a great piece by the chair of DSM-IV, Allen Frances.

http://www.opednews.com/articles/DSM-5-Field-Trials-Discred-by-Allen-J-Frances--121031-822.html

 

[rhiannon777]

Many medical issues are pretty clear-cut. Either you had a stroke or you didn't. You have syphilis or you don't. The mole is melanoma or it's not. Obviously, there is a margin of error in our lab tests, imaging, histological diagnoses, etc. but it's pretty well accepted that there is a "truth." Other medical issues are seen ase relatively clear-cut even when they're not. There's a sense that you either have hypertension or DM Type II or you don't, when in reality there is no true cutoff, just numbers set by medical authorities based on ressearch on outcomes etc.

Then you have medical issues which are clearly not clear-cut at all. Most of psychiatry consists of these issues. Perhaps one day, we'll have blood tests or brain imaging that will definitely diagnose some mental illnesses. We are moving that way with some diseases (such as the brain imaging of Alzheimer's). But I don't think there exists a true cutoff for, say, what constitutes normal bereavement versus depression. My attitude toward the DSM is that it constitutes our best hypotheses given what we know now. What I perceive we learn in residency is to care for a constellation of symptoms, taking into account a person's unique medical and social situation, rather than caring for a diagnosis.

In fact, I think most of the diagnoses we make in psychiatry are not black-and-white. There is room for error and debate. I may think the person fits criteria for MDD and you may think he better fits criteria for dysthymia. That does not mean either of us are misdiagnosing. I seriously doubt it's possible to tell someone they are fine when in fact they are "gravely ill" psychiatrically - it is pretty clear whether someone is severely functionally impaired by psychiatric symptoms.

All of medicine is a work in progress. That's why research is so important.

 

[nancysinatra]

Thanks for the responses everyone!

A patient's suffering is mostly independent of what we call it. Mostly.

Would you say the same thing in the dermatology forum?

If we could diagnose things precisely and we could treat some things highly effectively, would you want to go back to how things are now in psychiatry, all mushy and imprecise?

My program makes this huge point about trying to teach us empathy so that patients will know we understand their suffering. I'm all on board with that except that I highly suspect the reason they do it is because the "treatments" we have are not that great so of course the patients are suffering and need someone to empathize. We have a captive patient population!

I really do not understand all the fuss.
Which probably means I don't understand the situation.


- Other fields go through similar changes, but they tend to happen piece-meal, for one disorder at a time, rather than to the whole field at once, and they tend to be released by competing sub-specialty panels and organizing boards - letting history sort out which scheme we think is "right" until the next advance. This means that the diagnostic scheme and criteria are often in flux and not fully accepted by practitioners - and patients/payors/colleagues often have no idea which criteria a practitioner was using at the time, e.g. The numbers used to diagnose diabetes and hypercholesterolemia.

- The intended changes were put up for public comment and that comment process effected the outcome to some degree. Which other medical field has done that with its entire diagnostic scheme?
- The DSM process is heavily influenced by a group of "thought leaders," which will always make it somewhat suspect. And that is different from what other fields of human endeavor?
- The "thought leaders" are influenced to greater and lesser degrees by money and power. It has always been so.
.

These thought leaders don't seem to "think" too much if you ask me.

What would you think if internal medicine adopted our methods? What if they threw away Harrisons and replaced it with the ICD, stopped doing tests and studies, reduced their treatments to, oh, say, 35 PO medications which all work through 3 or 4 very similar mechanisms, stopped describing diseases in scientific terms, and only "diagnosed" things using a set of ever changing checklists created by their political leaders. Would people say this is ok?

Now I know people will respond by saying "psychiatry is different from those fields" -- but then they should explain why it's different, and why that's acceptable.

 

[vistaril]

What would you think if internal medicine adopted our methods? What if they threw away Harrisons and replaced it with the ICD, stopped doing tests and studies, reduced their treatments to, oh, say, 35 PO medications which all work through 3 or 4 very similar mechanisms, stopped describing diseases in scientific terms, and only "diagnosed" things using a set of ever changing checklists created by their political leaders. Would people say this is ok?
.

Of course not....people would say "why would they do such a stupid thing"......

what are we supposed to do though? if it's not there, it's not there....all of us wish we had the same kind of evidence base, methods, and treatments as internal medicine. Just wishing it doesn't make it so.

 

[billypilgrim37]

Would you say the same thing in the dermatology forum?

I'm not like vistaril. I don't troll around in the other forums trying to learn how to make more money!

That aside, I think you missed my point. It's not about being mushy or empathic. It's about the fact that people only come into a psychiatrist's office because they think they're sick/having worsened function (well, or trying to game meds, or lots of other surreptitious reasons, but those aside). It really doesn't matter if someone is having hypomanic episodes for 3 days or 4 days if those hypomanic episodes are bad enough to cause severe dysfunction. The criteria don't matter that much. The degree of impairment for the patient does. That's not all that mushy.

The only place where these fine distinctions in criteria matter is in large epidemiologic studies. You aren't going to have people that have "DSM-IV-TR depression, but not DSM5 depression." There was some concern this would happen with autism, but those concerns have mostly been allayed.

In the dermatologist's office, people walk in all the time, get told their mole is nothing to worry about, and walk out happy. Nobody comes into the psychiatrist's office thinking they might have a problem only to have the psychiatrist say "Oh, no, that's normal. No worries!" and go skipping out the door. Or at least this would be pretty rare.

Sure, if we had more fine tuned interventions, these details might matter more. But we don't, and we still manage to do quite a bit to help our patients.

Skin is really simple compared to the brain. It's amazing to me that we're so down on ourselves for poor understanding of the most complicated organ in the known galaxy.

 

[nancysinatra]

Of course not....people would say "why would they do such a stupid thing"......

what are we supposed to do though? if it's not there, it's not there....all of us wish we had the same kind of evidence base, methods, and treatments as internal medicine. Just wishing it doesn't make it so.

Well I guess I don't agree--I know a lot of people in the mental health field who actually don't seem to wish we had the same kind of evidence base, etc. I meet people every day, including other residents, who exhibit a lot of "soft" thinking and show no interest in science, the rest of medicine, or anything other than "being nice" to patients (and having to take as few exams as possible). There is definitely a category of people in psychiatry who fit this description. Where I'm coming from is having had to deal with that now for 4 years...

 

[billypilgrim37]

These thought leaders don't seem to "think" too much if you ask me.

It's very easy to parrot criticisms of DSM, and we've "grown up" in the easiest time to criticize. There are plenty of valid criticisms. But the idea that there isn't a lot of work, debate, and critical examination of (imperfect) data, and that a bunch of people just got together in hotel rooms and arbitrarily made up criteria is simply not true.

That doesn't mean the end product is great, all that useful, whatever.

Basically, I used to say all this same crap about how DSM was stupid, useless, misleading, invalid, blah blah blah. But I had one very good attending during all of PGY3 year at my SMI clinic who basically tore apart my arguments (basically the same lazy criticisms that are being thrown around here) and overwhelmed me with things I did not know before. I think the day I said something about schizoaffective disorder being a useless diagnosis was a day I will regret for the rest of my life. Not because I was wrong, but because I really didn't know why I was right or wrong, and I had my ass torn apart by somebody who did. I'm not as effective as arguing as she was, but I'm much more aware now of the things that I did not know.

Splik pointed out DMDD as a farce that shows problems with DSM. I totally agree. But I've had research conversations with the folks who were behind it, and I know several folks in their labs. I don't agree with Ellen Leibenluft or Danny Pine about this stuff, but those are two brilliant, thoughtful people with more experience and knowledge about child psychiatry than any of us, and the only reason I can really say what I say is because I have equally brilliant mentors who disagree with them. I'm not saying we can't have our own opinions despite not being experts in a field, but we shouldn't be so careless about things we don't know everything about. And that's how we sound when we make summary dismissals of DSM.

 

[billypilgrim37]

...who exhibit a lot of "soft" thinking and show no interest in science, the rest of medicine, or anything other than "being nice" to patients...

To be fair, various forms of "being nice" have a lot of evidence base (research on nonspecific therapeutic alliance as, validation in DBT, rolling with resistance in MI, assigning the sick role in IPT, etc).

 

[nancysinatra]

I'm not like vistaril. I don't troll around in the other forums trying to learn how to make more money!

That aside, I think you missed my point. It's not about being mushy or empathic. It's about the fact that people only come into a psychiatrist's office because they think they're sick/having worsened function (well, or trying to game meds, or lots of other surreptitious reasons, but those aside). It really doesn't matter if someone is having hypomanic episodes for 3 days or 4 days if those hypomanic episodes are bad enough to cause severe dysfunction. The criteria don't matter that much. The degree of impairment for the patient does. That's not all that mushy.

Well fair enough--on a certain level I completely agree; it's just that I wonder if more people in our field made a fuss about our not having a better evidence base and all that if, suddenly, voila, we might have more to offer that hypomanic patient? And haven't we all probably misdiagnosed a borderline with bipolar or vice versa? If we had more objective measures and could be sure who has which condition, wouldn't that be good? But the APA just spent all this dough working on the new DSM and yet in four years of residency I haven't heard of very many scientific advances in our field.

It probably varies a lot between programs how much emphasis there is on basic science but I can tell you at my program, it isn't a lot.

In the dermatologist's office, people walk in all the time, get told their mole is nothing to worry about, and walk out happy. Nobody comes into the psychiatrist's office thinking they might have a problem only to have the psychiatrist say "Oh, no, that's normal. No worries!" and go skipping out the door. Or at least this would be pretty rare.

Well ok, but what if our diagnostic categories are so flawed that our sick:normal ratio is being inflated? The best example I can think of would be homosexuality from the older DSMs.

Skin is really simple compared to the brain.

I'm pretty sure I can produce a few people in the mental health field, who, if you actually try to have a discussion with them, you will come out questioning this belief.

 

[nancysinatra]

Basically, I used to say all this same crap about how DSM was stupid, useless, misleading, invalid, blah blah blah. But I had one very good attending during all of PGY3 year at my SMI clinic who basically tore apart my arguments (basically the same lazy criticisms that are being thrown around here) and overwhelmed me with things I did not know before. I think the day I said something about schizoaffective disorder being a useless diagnosis was a day I will regret for the rest of my life. Not because I was wrong, but because I really didn't know why I was right or wrong, and I had my ass torn apart by somebody who did. I'm not as effective as arguing as she was, but I'm much more aware now of the things that I did not know.

Then the burden of proof should be on the authors of the DSM to write their book in such a way that it explains why these categories matter and why it is not useless, invalid, etc. I haven't seen the whole thing yet nor have I done due diligence and completely poured over the DSM-IV, but if a persuasive argument for its usefulness is there, people certainly don't talk about it much. I've never heard an attending convince a patient of why these categories matter. If that's our science, why isn't it being conveyed to patients? Why isn't it on the PRITE? When you go to an internist, if you ask about etiology, they will usually at least try to tell you. If you go to a psychiatrist, you get diagnosed with a checklist and if you ask why they will say "because that's what's on the checklist."

My problem is not so much with the DSM itself in some technical way, it's with the ever changing nature of the DSM, and with the very conspicuous lack of an agreed upon textbook in our field that describes things scientifically. That's what I wish the "leaders" would provide.

And if the DSM really is so great, if it is the be all and end all of all of medicine for all of time throughout the universe, then why isn't there a DSM for every other specialty?

 

[nancysinatra]

To be fair, various forms of "being nice" have a lot of evidence base (research on nonspecific therapeutic alliance as, validation in DBT, rolling with resistance in MI, assigning the sick role in IPT, etc).

Of course--but there are people in psychiatry who, all they do is "be nice." People that you can't reason with under any circumstances. And these people are doing CBT and challenging the patients' "thoughts"!

If someone is going to argue that psychiatry is the most competitive, most technologically advanced field in all of medicine, with the most impressive line of recent advancements, I say go for it. All I'm saying is that I don't think we're number one. Maybe we should aim a little higher. Maybe psych residents should be required to do significant research, much like happens in competitive fields like derm.

 

[F0nzie]

I have been greatly surprised by my residency training... Initially I came into psych thinking I was going to make people feel better by strictly following evidence based guidelines and titrating medications as an expert psychopharmacologist. I never believed that my relationship with the patient mattered. I thought psychodynamic therapy was hocus pocus and that learning therapy was pointless. But after having worked with individuals for 2 years now, the patients that are truly getting better are the ones I am doing psychodynamic therapy with. The human experience is a unique aspect of our existence that can be shared, yet we lose sight and overly focus on the facts and aspects that can physically observed and measured (as we have been trained in medicine). Most of our patients didn't grow up with sunshine, green grass, white picket fences and loving/caring parents then suddenly get depressed and feel the need to put a gun to their head. Empathy and validation goes a long way in Psychiatry. If we give up on this aspect of Psychiatry we are making a huge mistake.

 

[vistaril]

Well I guess I don't agree--I know a lot of people in the mental health field who actually don't seem to wish we had the same kind of evidence base, etc. I meet people every day, including other residents, who exhibit a lot of "soft" thinking and show no interest in science, the rest of medicine, or anything other than "being nice" to patients (and having to take as few exams as possible). There is definitely a category of people in psychiatry who fit this description. Where I'm coming from is having had to deal with that now for 4 years...

but how can you know they don't wish we had a decent evidence base?

I think about it like this....imagine you are stranded on an island and are going to need to kill prey to survive. You are well aware that guns/rifles make far more effective weapons to kill prey than homemade bow and arrows. So would it be wrong to start focusing more on practicing with bow and arrows, even if they arent that great at killing deer? Of course not....that's what you can possibly get. It doesn't mean one wouldn't prefer a rifle......

of course, maybe you know because they flat out tell you...that's always one way to find out

 

[vistaril]

Basically, I used to say all this same crap about how DSM was stupid, useless, misleading, invalid, blah blah blah. But I had one very good attending during all of PGY3 year at my SMI clinic who basically tore apart my arguments (basically the same lazy criticisms that are being thrown around here) and overwhelmed me with things I did not know before. I think the day I said something about schizoaffective disorder being a useless diagnosis was a day I will regret for the rest of my life. Not because I was wrong, but because I really didn't know why I was right or wrong, and I had my ass torn apart by somebody who did.

the problem with this line of reasoning in general is that taking the right turn in the major fork in the road and then being sort of hazy on the exact directions three turns later >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> missing the initial turn but knowing all the little side streets like the back of your hand. The first person will get a lot closer to the final destination than the second.

 

[DOC PENGUIN]

Of course not....people would say "why would they do such a stupid thing"......

what are we supposed to do though? if it's not there, it's not there....all of us wish we had the same kind of evidence base, methods, and treatments as internal medicine. Just wishing it doesn't make it so.

Vistiral, If you don;t like it? Why not go on a research fellowship and make it happen? Fields do not progress in groundbreaking events. Rather done in layers and layers of Cohorts, Editorials and RCT's. That's the nature of Science. You are right that wishing for the future is almost useless, but just because something is slow (Empirical science), does not mean it is non existent. in the 50s, we thought CVD was caused by stress and genetics and there was almost nothing we could do. Then came along Basic research that morphed into translational and clinical research (Seven Countries Study, Brown and Goldstein.) Today CVD is treated with Statins, Diet, Exercise and Surgery. But we did not exactly develop all of this in a few years.

 

[notdeadyet]

Empathy and validation goes a long way in Psychiatry. If we give up on this aspect of Psychiatry we are making a huge mistake.

Just want to quietly point out that you do not lose empathy with the practice of evidence based medicine. Sometimes folks might give the impression that you have to lose empathy to be EBM or that you can't practice EBM if you want to be an empathetic practitioner. It's a false dichotomy.

 

[F0nzie]

I think you're missing my point. You can ask a patient SIGECAPS and be nice about it and I am sure the patient would appreciate your bedside manner. However, the lives we are helping have deeper meanings than the statistics we try to make them represent.

 

[Armadillos]

While obviously psych has a long way to go when it comes to figuring things out scientifically, at some level I think its historically near sighted to give psych too hard of a time.

There have been physicians for 2000+ years and probably not much really changed for like 1800 of those years. I mean penicillin is less than 100 years old, and its only been pretty recently that physicians had any idea WTF was going on or what their treatments did. Psych seems to be a little "behind the curve", but pretty much everything related to the study of the brain has historically been "behind the curve" compared to where analogous knowledge is for other organ systems.

 

[vistaril]

While obviously psych has a long way to go when it comes to figuring things out scientifically, at some level I think its historically near sighted to give psych too hard of a time.

There have been physicians for 2000+ years and probably not much really changed for like 1800 of those years. I mean penicillin is less than 100 years old, and its only been pretty recently that physicians had any idea WTF was going on or what their treatments did. Psych seems to be a little "behind the curve", but pretty much everything related to the study of the brain has historically been "behind the curve" compared to where analogous knowledge is for other organ systems.

all fair points, but physicians in 1600 weren't much good. It's not of much use to us practicing *today* to know that in 2140 psychiatrists may be practicing under a much larger and more impressive evidence base.

 

[billypilgrim37]

the problem with this line of reasoning in general is that taking the right turn in the major fork in the road and then being sort of hazy on the exact directions three turns later >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> missing the initial turn but knowing all the little side streets like the back of your hand. The first person will get a lot closer to the final destination than the second.

Dude, get google maps.

 

[AbcJuly]

The Chair of my Department sat on the DSM5 committee. So, he's been teaching it to us all year (I'm PGY-1). The biggest changes are in Axis II it seems. There are also some new diagnoses and some that got cut. It's going to be awesome!

 

[vistaril]

The Chair of my Department sat on the DSM5 committee. So, he's been teaching it to us all year (I'm PGY-1). The biggest changes are in Axis II it seems. There are also some new diagnoses and some that got cut. It's going to be awesome!

here is all that matters: Will the publication of the dsm-5(vs the dsm4) help me treat a single patient in terms of giving them better quality of life? I can say, with near total certainty, that the answer to that question is no.

 

[nancysinatra]

all fair points, but physicians in 1600 weren't much good.

How do you know that? For all we know, the medicine was better back then.

People SAY that life expectancies and all are always increasing (unless you live in my part of the US, in which case they're stagnating), but when did they start keeping records? The 1800s, right? Right in the midst of the Irish Potato Famine and the Industrial Revolution.

I bet when anthropologists unearth us and our culture in 2500 years, then assuming my hospital and others like it have not been obliterated by a meteorite in the intervening time, the anthropologists are NOT going to be posting little plaques in museums next to our antiquated tools ("Here is a DSM") that describe our civilization as "much more advanced than the people in 1600 when it comes to mental health." No, I bet they won't even notice.

 

[nancysinatra]

but how can you know they don't wish we had a decent evidence base?

Because I'm talking about people that have never read an article, not ever.

 

[OldPsychDoc]

The Chair of my Department sat on the DSM5 committee. So, he's been teaching it to us all year (I'm PGY-1). The biggest changes are in Axis II it seems. There are also some new diagnoses and some that got cut. It's going to be awesome!

[Inigomontoya] "You keep using that word. I do not think it means what you think it means." [/inigomontoya]

 

[erg923]

here is all that matters: Will the publication of the dsm-5(vs the dsm4) help me treat a single patient in terms of giving them better quality of life? I can say, with near total certainty, that the answer to that question is no.

That means its useless to you. Doesn't mean its useless for the overarching purpose of improving the understanding about the nature of psychiatric disturbances/entities. The DSM was (and was never intended) never used a treatment manual anyway...

 

[michaelrack]

I bet when anthropologists unearth us and our culture in 2500 years, then assuming my hospital and others like it have not been obliterated by a meteorite in the intervening time, the anthropologists are NOT going to be posting little plaques in museums next to our antiquated tools ("Here is a DSM") that describe our civilization as "much more advanced than the people in 1600 when it comes to mental health." No, I bet they won't even notice.

it will be noticed by historians- I took a history of science class in college about 20 years ago, and I think the DSM will make it in the history of science textbooks at least as a footnote several millenia from now.

 

[vistaril]

Because I'm talking about people that have never read an article, not ever.

Ha....that is a pretty good indication.

But seriously, sometimes being a 'student' of true evidence based psychiatry can be frustrating. Do cochrane review searches for many/most practical questions in psychiatry related and the answer is some variation of: there isn't any data to support this intervention is clearly better than placebo. I can see how that would get frustrating for some people.