Archive for the ‘mental health disorders’ Category

DSM-comments and critiques: part 2

Sunday, August 19th, 2012

I'm still traveling, but back in the swing of writing posts on the numerous changes to DSM-5 the Diagnostic and Statistical Manual of Mental Disorders, that is supposed to be published (finally) in May of 2013. I've been reading background material, papers with advance critiques and older criteria for some of the diagnoses.

I still can't add photos as I'll be using my iPad until I get home four days from now, so I'll give you a URL or two and some titles you can Google.

I'll start with mentioning a long, multi-part fascinating paper that is appearing in 'Philosophy, Ethics and Humanities in Medicine'. It's called "The six most essential questions in psychiatric diagnosis: a pleuralogue."  The second author, Allen Frances, a Duke School of Medicine Emeritus Professor of Psychiatry, was the leader of the group that put together DSM-IV. I'll come back to these articles in a later post, but used the first one to find short commentaries on DSM-5.

The lead author, Dr. James Phillips, is an Associate Clinical Professor of Psychiatry at Yale. In November, 2011 he wrote an article for 'Psychiatric Times,' titled "The Great DSM-5 Personality Bazaar," and in March of 2012, in the same publication, a piece titled "DSM-5 In the Homestretch--1. Integrating the Coding Systems."

That first piece told of diagnoses, e.g., narcissistic personality disorder, that were excluded in drafts of the new manual and later re-included. The total number of Personality Disorders ended up at six, down from ten, at the time Dr. Phillips wrote his commentary.

One category that was removed was Paranoid Personality Disorder. It seemed worthy of inclusion to Phillips, certainly as much so as another that was kept. Personality Disorder NOS (not otherwise specified), was apparently changed to Personality Disorder Trait Specified (PDTS), which to me at least is a potentially confusing acronym. There is PTSD after all, a term most of us have some familiarity with.

Dr. Mark Zimmerman et al. published a study of 2,150 psychiatric outpatients (you  can find it at which said that DSM-IV's method, using three trait categories: absent, sub threshold or present, was just as effective as the proposed diagnostic approach of DSM-5.

Dr. Phillips, in his later article, mentioned coding, how to relate the International Classification of Diseases (ICD) with the DSM, often for billing purposes. Our country has a treaty obligation to use the ICD and at present is using a "clinical modification" of the 1978 ICD-9 version. Some diagnoses used by US mental health (MH) therapists aren't in the ICD at all and the new American version of the international coding system, ICD-10CM, originally supposed to be available in October 2013, has been delayed. Of course the rest of the world already uses ICD-10.

Dr Frances in an April 25, 2012 piece in the New York Times, "Diagnosing the DSM-5: Shrink Revolt," was said to be opposed to the first draft of the new version as being too promiscuous with its diagnostic labels. He cites the proposed Binge Eating Disorder which may be present in 6% of the total US population (using the proposed definition).

He then commented, "And that is before the drug companies start marketing something for it."

He had similar reservations about three other tentative new DSM labels: one could be applied to kids with "typical temper problems;" another to anyone who has lost a spouse and is grief-stricken for two weeks. The third, "Psychosis Risk Syndrome," in his opinion, could misidentify many youngsters and treat others with anti-psychotic meds without any evidence that such early treatment is helpful.

By the May, 2012 meeting of the American Psychiatric Association (APA), two of those four problematic categories had been discarded. Dr Francis was still not content and published a NYT Op-Ed piece on May 11th titled "Diagnosing the D.S.M.," which said it's time to open the DSM's revision to all the MH disciplines as well to the primary care doctors who prescribe most of the drugs used for MH disorders.


DSM-V comments & critiques: the Rosenhan studies rehashed

Friday, August 17th, 2012

It won't be published in its final official form until May of 2013, but the new version of the Diagnostic and Statistical Manual of Mental Disorders, AKA DSM-V,  has already spawned lots of critiques and courses.

My wife, still doing some pro bono therapy, gets at least one offer a week to attend a seminar on DSM-V. I glance at those, but spend much more time on the background comments, including those from the lead editor of DSM-IV.

But let's start with the Rosenhan experiments. In 1973 an academic who was professor of psychology and law at Stanford had eight sane participants (himself among them) present to 12 hospital admission offices in five states with a chief complaint of "hearing voices." They said the messages conveyed were often unclear, but contained the words "empty," "hollow," and "thud."

In each case the voice was unfamiliar and of the same gender as the complainant (the group included one younger psychology graduate student, three professional psychologists, one psychiatrist, a pediatrician, a painter and a housewife). They gave false names, vocations and employment history, but all other details of their lives were true.

All were admitted to psychiatric wards, whereupon they acted completely sane and behaved as they normally would.

None of the staff recognized they were normal and 10 of them were given the diagnosis of schizophrenia. They remained in the hospital for a week to 52 days (average of  19 days) where a number of other patients suspected they were sane (35 of 118 did so with many vocalizing that the so-called patients were journalists or professors).

When the results of the study were initially made known, the staff of a week-known teaching/research hospital said they wouldn't make such mistakes.

At that point, Dr. Rosenhan set up a second experiment, telling the staff of the renowned center that he would send them  one or more spurious patients over the next three months.

In reality he sent nobody, yet the hospital staff, suspected a number of the 193 patients who were admitted during that time frame; the physicians, psychologists, nurses and techs alleged that 41 were fakes and, of those, 23 were suspected by one or more psychiatrists.

During their admissions all of the first group publicly took copious notes and the typical comment in the nursing notes was "Patient engaged in writing behavior."

They were only discharged with a diagnosis of schizophrenia in remission after admitting they were crazy and all were given medications  (which they did not swallow; they noted many patients did the same).

They seldom saw physicians except for fleeting encounters; in only 6% of these did staff doctors stop and chat or talk with them.

One comment about this famous study is, "It's hard to be sane in an insane setting?

Sorry, I can't give you links or photos, but I'm on an unplanned trip and using my iPad instead  of my laptop.

Romping through the Mental Health field: part one: various clinicians and MH medications

Tuesday, July 24th, 2012

talk therapy often helps

Although my training was in Internal Medicine (IM) with a subspecialty in Nephrology (nephros is Greek for kidney), I've had a long-standing interest in Mental Health (MH) issues. My medical school (University of Wisconsin circa 1962-1966) included four years of MH classes. Then I supervised, in various Air Force roles, mental health departments and later commanded a hospital with 90 MH beds (versus 15 each of IM, Peds, Ob-Gyn & Surgery). But there's an even more important reason for me to care about the wife is a clinical social worker, i.e., one who sees patients (they now call them "clients," but I don't) with MH problems.

Since I'm married to a MH therapist, I'm familiar with the Diagnostic and Statistical Manual for Mental Disorders, DSM for short. It'a a publication of the APA, the American Psychiatric Association and is the "lingua franca," the standard terminology for all working in the MH field. That includes psychiatrists, who are, of course, MDs and therefore can prescribe medications (I often get the impression that's all many of them do these days), psychologists (PhDs who, in general, can't, although two states, New Mexico and Louisiana, have enabled some who obtain a master's degree in clinical psychopharmacology to write RXs for MH meds only), clinical social workers (who have a Masters degree or, occasionally, a PhD, but can't prescribe pills), and a variety of other therapists (e.g., marriage and family therapists), most of whom have a Masters degree and can't prescribe meds.

Of course those of us who have MD degrees and aren't MH specialists can also order MH meds; internists and family practice physicians do so fairly often. I saw our FP today for  my sore hand and raised the subject; my impression was she'd be uncomfortable writing kids' MH prescriptions, but is quite at home with adults. I'd think that most surgeons and Ob-Gyn physicians would be less likely to write RXs for many of these drugs without consulting another physician who's used to the meds and their side effects. The standard anti-anxiety drugs would be an exception, of course, and perhaps they might treat a patient with relatively mild depression.

Whenever I saw a patient with significant depression or other major MH issues I put in a call to the psychiatrists.

So who is available to treat this youngster?
Mostly likely his pediatrician.

I didn't know much about pediatric mental health issues. I found an online paper titled "Strategies to Support the Integration of Mental Health into Pediatric Primary Care" from an organization I at first thought was part of the NIH. Then I Googled it and realized the National Institute for Health Care Management wasn't governmental, but a non-profit. The Executive Summary of "Strategies" stated up to one in five children and adolescents in the U.S. experience MH issues with 50% of all lifetime mental disorders being seen by age 14.

The issue for Pediatrics is there aren't very many psychiatrists who specialize in kids; so three ideas have been suggested: telemedicine for remote Pediatric practices; co-locating a pediatric psychiatrist in a large Peds practice or collaborative care via what's called the "medical home model." But for Pediatrics in general, the integration of MH care into primary care is desperately needed; again there just aren't enough Peds therapists to see all the youngsters with MH issues.

I'll get back to the DSM in my next post; its history is interesting and its latest version, to be published in May 2013, has caused a lot of controversy.