Tuesday, February 16, 2010

DSM: The Everlasting Gobstopper of Psychiatry


The DSM is the Everlasting Gobstopper of psychiatry, providing a seemingly endless store of material for bloggers, journalists, academics, and other commentators.

I looked through the comments on my last post and was impressed by how articulate they were. I'll spend the next few posts commenting on some of the comments. How's that for narcissistic exploitation of one's own blog?

S pointed out that “a reasonable, experienced, compassionate doctor will not be bound up by DSM diagnoses,” and accurately followed that up with “but I suspect all of us here know that there are plenty of doctors who can't see past rigid categorization or have a two-dimensional view of their patients.”

I agree. Michael First, who was the editor of DSM-IV, once told me, “We used to joke that DSM should come with a combination lock and you can only open the book if you agree to really explore what is going on in the patient’s minds.” I think of DSM is a map into the mental world. It allows us to locate a patient in a general region, but not much more than that. To truly make the diagnosis, we have to do the messy work of talking with the patient and exploring what’s going on. In fact, the term “diagnosis” is a misnomer and should probably never have been borrowed from the rest of medicine, since it implies a precision utterly lacking in psychiatry circa 2010.


Dr. Peter Huang likes the new dimensional aspects of the DSM-V, but is concerned that the new disorders being proposed "will serve as an even bigger seed that Big Pharma + the APA + the FDA will use to increase further the insanely vast quantities of psych meds that are prescribed.” This is also Dr. Allen Frances' main critique in his essay,
Opening Pandora’s Box: The 19 Worst Suggestions For DSM5. I agree that this is an inevitable consequence of elaborating the DSM, but only if we psychiatrists acquiesce. Some of these "changes" represent little more than a shuffling around of criteria from one label to another. The two risk syndromes (for psychosis and dementia) are potentially more insidious and might be exploited by drug companies for commercial gain. For this reason, I find it rather unlikely that both will make it into the final version--I predict that mild dementia (in the new vocab, "mild neurocognitive disorder") will make it through the gauntlet, but not "risk syndrome for psychosis."

Dr. Joseph Arpaia points out that DSM is mute when it comes to how the environment produces psychiatric symptoms: “The minimizing of the environmental effects means that the brain's attempts to adapt to the environment are seen as inherent brain pathology. This is as absurd as stating that an immune response to a bacterial invasion is an inherent immune pathology.”


However, the reason DSM does not mention environment is that it attempts to be “agnostic” when it comes to statements of causation. Yes, depression can be caused by many things but DSM simply runs down the list of symptoms. This speaks to the issue of how the document is used. If someone invented a DSM robot (perhaps in Freud's likeness), such a machine would, indeed, simply go through the lists and makes a bunch of diagnoses divorced from context. But thoughtful clinicians, whether psychiatrists or psychologists or social workers, don’t use the manual this way. Don't expect DSM to be more than it is, which is bare-bones descriptive psychiatry. At this point, we know too little about causation to do anything more than describe symptoms.

That's all for now--stay tuned for our next installment of "Commenting on the Commenters."

58 comments:

Ronald Pies MD said...

Hi, Danny...Yes, the DSM-5 seems to be a kind of massive societal Rorschach pattern, on which we can all project our deepest hopes, fears, loves, hatreds, and fantasies!

You and your readers may be interested in two posts on the Psychiatric Times website (where you also blog).

Sid Zisook and I have a piece on the "bereavement exclusion". We support the DSM-5 in eliminating the BE, but we also criticize the DSM for avoiding any real "phenomenology" in diagnosis (we explain and illustrate). Here is the link:
http://www.psychiatrictimes.com/home/content/article/10168/1523978

I also have a piece that should appear tomorrow on the PT website, which is a kind of response to your blog on Steve Moffic's piece, re: who should be a "diagnostician" for DSM-5. I try to take a kind of middle-ground position, between you and Steve!

And so it goes, as Kurt V. would say.

Take care...Best regards, Ron

Ronald Pies MD
Editor in Chief
Psychiatric Times

Thai said...

Nice post

I am only an ER doc but DSM does tend to get a lot of use in my line of work, what with involuntary commitments and all.

Supporting your notion that "a reasonable, experienced, compassionate doctor will not be bound up by DSM diagnoses", I have often wondered whether the statistics that went in to the epidemiology of DSM were Gaussian and not Cauchy (or Lorentz)?

Do you know?

I only ask as my clinical experience suggests to me that whoever put DSM together did so by imposing a Gaussian analysis on our Cauchy world. If it is Gaussian, it is wrong and needs to be completely re-written for DSM simply does seem to account enough for what I have read statisticians call "fat tail probability events"- the bane of both patients and emergency physicians like myself. Obvious examples might include our inability to predict suicide itself, etc...

Anyway, I was just curious to know if you knew?



FWIW- I also sometimes find that psychiatry is ever so much easier for practicing docs like me to understand when I remember that all thoughts are really just information and therefore must be energy. And if they are energy, the conservation of energy must apply to thoughts and the mind itself. With this model, it becomes easy to conceptualize a series of complex/chaotic systems cooperating/competing with each other just like everywhere else in the human body.

... In this regard I would tend to disagree with your statement "the term “diagnosis” is a misnomer and should probably never have been borrowed from the rest of medicine" and would instead say that you simply need to re-frame the viewpoint from which you are viewing the model we have of both psychiatry and the rest of medicine. They still seem quite similar to me.

Anyway, I tends to find my conservation of energy- complex/chaotic system model much more helpful whenever I am unable to fit a square diagnosis peg into a round DSM hole.

... Or as old Heisenberg once reminded us, the best we can ever do is "locate a patient in a general region, but not much more than that"- to use your own words. ;-)

Anyway, it was a pleasure to read your wonderful post.

Be well

Anonymous said...

Hi, All--

I have a take on "diagnosis" that is a bit different than Danny Carlat's, and also different than the more probabilistic one described by "Thai".

You can find the article at:
http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1524443

I believe we can and should make "diagnoses", but that we ought to acknowledge that diagnoses are just provisional tools, aimed at alleviating suffering and incapacity--not reified "objects" in the world. Moreover, the nature of diagnosis ought to incorporate phenomenology--the patient's felt experience--not just DSM symptom and behavioral check lists!

Best regards, Ron Pies

Joseph Arpaia, MD said...

Danny,

I'm going to respectfully disagree with what seem to be your ideas behind your reply to my comment.

First you state, "But thoughtful clinicians, whether psychiatrists or psychologists or social workers, don’t use the manual this way."

My experience is the opposite, or else there are few thoughtful clinicians out there. A lot of my patients have been diagnosed by the "cookbook" method when they come to me, and I think the situation will only get worse with the DSM V.

I see this especially in the legal arena where a patient has an "IME" by a psychiatrist or psychologist who always seems to be able to make multiple axis I and Axis II diagnoses by checking off any symptom that the patient remotely fits. Its absurd, and not a valid use of the DSM, but try stating that in court. The DSM is just too easy to misuse.

I also disagree with the principle you seem to be putting forward which is that descriptions of symptoms as stated in the DSM have some sort of clinical meaning. I just don't see that. There are over 100 combinations of symptoms which will qualify for a Major Depressive Disgnosis. Many of those overlap with other disorders. Given that the patient is probably inaccurate in reporting the symptoms and their frequency (for example a spouse usually gives me a very different report), then the specificity of the description as a diagnostic instrument indicating treatment is so low as to be useless.

Dr. Pies' article that he referenced in his comment is indicative of another area of disagreement. His position, and that of the DSM is that a symptom complex is a diagnosis regardless of the environmental factors, bereavement is the example in his article.

I disagree completely. The same symptoms arising in different environments suggest different diagnoses because different treatments are usually necessary. It is this way in other fields of medicine. Someone with chest pain and dyspnea on exertion does not necessarily have the same cardiac condition as a patient with those symptoms at rest. And the treatments (and prognoses) are different. True, descriptions are used in oncology, but those are strongly correlated with biological variables that can be measured with far more precision than anything in psychiatry.

I think that the idea that the DSM is based on science is absurd. When I was at CalTech I learned that to study something scientifically you needed precise, accurate measurements, and rigorously controlled experiments. Psychiatry has neither. The leaders in the field should admit that we are really clueless about mental illness, but we are doing the best we can, and perhaps in a hundred years we'll actually know something.

While I think we disagee I greatly appreciate the time you put into this blog and the replies you made to the people who commented.

Thanks,
--Joe

Thai said...

@Joe re: "My experience is the opposite, or else there are few thoughtful clinicians out there. A lot of my patients have been diagnosed by the "cookbook" method when they come to me, and I think the situation will only get worse with the DSM V"

Much of the mental health world is nothing but a jobs program imo (the financial conflicts of interest are worse amongst the practitioners than they are amongst the drug companies). This "check box medicine" we are both witnessing in this regards is nothing but an attempt to systematize processes to make them seem like we have "tamed the beast" so to speak.


And Re: "I think that the idea that the DSM is based on science is absurd."

I hate to imagine this might be true. This would feed in my ever growing tendency towards the opinion that the practitioners of of psychiatrists have more financial conflicts of interest than even the drug companies.

Still, do you know if most of the studies quantifying and qualifying the various DSM conditions are based on Gaussian analysis?

If they are, you could easily see why they would be wrong.

Joseph Arpaia, MD said...

Thai,

I'm not sure about the statistical methods behind the DSM. In my opinion the problem is deeper than that.

Statistical methods are based on measure theory. The phenomena that are to be analyzed by statistics must exist as elements of a mesaureable space. A measureable space has a mathematical definition and the phenomena we are attempting to measure in psychiatry do not meet that definition, in my opinion at least. So it doesn't matter what statistics are used, the basic requirements for using the statistics are not met.

For example take the Ham-D. If that is a measure then higher scores on the measure mean the patient is more depressed in some manner that is independent of the measure, effect on their life, or difficulty to treat. But that is not what we see clinically. There is a rough correlation between scores on the Ham-D and the effect of depression on the person or the difficulty of treating the depression, but the correlation is low. So the Ham-D is not a measure and points on the Ham-D do not form a measureable space and so you can't really do statistics with it.

Sure you can plug the Ham-D scores into a statistical program and get results, but the results are really meaningless. As one of my math professors said repeatedly, 'More than one bridge has collapsed because someone ran a program without making sure that the mathematical assumptions demanded by the program were met by their data.'

Perhaps fuzzy set theory may have some ability to provide more valid mathematical tools, but I am not that familiar with it.

Thai, since our interchange is diverging from the theme of the blog perhaps we should continue by email if you wish. You can reach me at jparpaia@mac.com

--Joe

Dr John said...

I would echo Dr Arpia's wonderful and astute comment. To make the statement "But thoughtful clinicians, whether psychiatrists or psychologists or social workers, don’t use the manual this way." is completely out of touch with how mental health services our delivered and how the DSM shapes the way people choose to look at these problems. I wonder if Dr Carlat would offer that comment in a court room? If he did he would have his bones picked clean by a lawyer. To say the DSM is based on science is to have a very distorted view as to what constitutes science. This is an issue of which volumes have been written on but psychiatry and its researches and those who put the DSM together appear to believe that data collection and creating constructs constitutes science. It does not appear the appreciate the very concept of mental illness is socially derived. I believe the opinions of Dr Carlat and Dr Pies are distorted by "sunk cost bias". Like the writers of the DSM they have too much intellectual and financial capital invested to confront the horror that there is absolutely nothing that constitutes real knowledge behind any psychiatric diagnosis in the way we have real knowledge in the other branches of science and medicine. Dr Carlat makes the point the DSM is "agnostic". It has to be agnostic because it must be. There is no knowledge behind any dx and as Dr Arpia points out we really cannot know anything objectively at all.Psychiatry and psychiatrists as a group will never admit this because it would mean admitting we are not like real Drs and not a valid branch of medicine.It is too scary and dangerous to admit this but anyone who takes the time to do even a rudimentary comparison of what constitutes scientific knowledge in psychiatry vs. the rest of the scientific community can see how obvious this is. That is unless you are confined by the box of a graduate education in psychiatry. "No satisfaction based upon self-deception is solid, and however unpleasant the truth may be, it is better to face it once for all, to get used to it, and to proceed to build your life in accordance with it." Bertrand Russell

Joel Hassman, MD said...

The beauty of our field is the shades of gray that define diagnosing and treating illnesses that are more so amenable to interventions. Going back to my comment at your prior posting about this matter, NOS diagnosing has a legitimate place.

The point I struggled with in training that I grew to accept and appreciate on my own was the full Axis 1-5 process in your assessment. A responsible and wise clinician realizes that psychological struggles have multiple factors, be it personality traits, medical problems, psychosocioeconomic factors, and where the patient is versus was in function.

I think a good many providers now skimp if not ignore the full coding process if not asked to fill out treatment plans as part of reimbursement, and that is why you see these cookbook attitudes as debated above. And maybe why you see lower response rates to medication trials that ae just targeted to an Axis 1 provisional diagnosis by a quick assessment.

By the way, I still take exception to Dr Pies' attitude per what I have read and heard him say in comments at other sites that bereavement should be quickly lumped into a depressive diagnosis. I really wonder how many patients he advised go on meds came back to thank him, versus those who did not as there were more consequences than benefits. I have met my share of the latter who relate too many docs were quick to scribble a script and literally say "call me in 4 or more weeks."

That is not psychiatry, colleagues. That is basically being dismissive.

Joseph Arpaia, MD said...

I don't want to sound cynical when I criticize psychiatry for not being scientific. We can still observe and attempt to improve our outcomes based on our observations.

After all, fire and the wheel, not to mention indoor plumbing, were discovered without placebo controlled double-blind studies.

I just think we should not cloak our attempts at diagnosis and treatment with the mantle of scientific authority.

--Joe

Anonymous said...

I have zero credentials other than being human, but regarding the "scientific" basis of the DSM, you might find a new book of interest: Manufacturing Depression by Gary Greenberg. On my mother's grave, I swear I have no connection to the author or the publisher....just as I have none to Charles Barber's Comfortably Numb or Alison Bass' Side Effects. But as a consumer and mother, it seems to me we are "gussying" up hypothesis and theory as "science" when in fact, it is not. I was confused recently about the "questionaire" approach when I realized the neurologist who diagnosed my mother with Alzheimer's had a list of questions....but it was pointed out to me that she was asked "who is the President" and "count backwards by 3's", not "how do you feel this week compared to how you felt last week?"

I would not be "anonymous" if I were astute enough to figure out how to do this google account/identity thing....perhaps I'll work on that since being anonymous doesn't give my "voice" much merit. But, thank you, Dr. Carlat, for your important discussion of these topics.

gewisn said...

A friend has been diagnosed with recurrent acute pancreatitis on the basis of his reports of episodic terrible pain and digestive symptoms. Sometimes the lab values correlate with the pain, but most often do not - so there is no "objective" proof of the attacks or their cause. The original attack was provoked by an endoscopic procedure and had clear laboratory and CT findings. However, all the rest of the attacks had no objective proof of either the complaint or the disability endured.
According to most of the critics of the entire DSM history, there was no diagnosable condition and all the recurrences were the fantasy of the makers of generic ibuprofen.
My analogy does not make all of the DSM correct or all of what is done in the name of psychiatry right - but it does point out the enormous utility of syndromic diagnosis. You know, like the diagnosis of URI - the one with no completely reliable objective findings in the PCP office.

Stephany said...

Exactly, Dr. Hassman, grief should not be medicated. In my quest to fully feel the grief following a sudden and violent death of my father, I declared to grieve, without a medication numbing.

There are reasons some people may need the medications immediately following a death like that, but PRN is the key word here.

It hurts. Plain and simple, feeling the pain and loss hurts, and this is a very interesting topic, to bring up, because medicated grief DOES return to bite you in the A** later in life if you have not dealt with it, and to lump the category of fully feeling emotions into depression, which then harbors possible long term SSRI's, etc, I applaud any doctor (like mine!) who supports a patient by listening and allowing them to grieve without pills.

Therapy first right?

I do believe that the DSM is used largely for accounting reasons. The insurance billing, right down to ambulance drivers all want/need a code for billing purpose, and many people with mental illness dx/labels must have certain codes/labels to qualify for housing, and SSI, etc.

As witness to my 22 year old being given just about over a dozen DSM codes in her short life time, only to have the mental illness ones recently thrown out and replaced with PDD/autism, and having many psychiatrists tell me the book holds weight for reasons I listed above, you can call me a skeptic.

I may not be adding much to this discussion here, but thought I'd say it's a good discussion, and the general public deserves and needs to know the truth behind the creation of the DSM-5, so any transparency and debate is completely welcomed by someone like myself.

Anonymous said...

I believe that DSM-III did have a "bereavement exclusion" but then went on to suggest that if grief lasted more than two months, it might be a suggestion of MDD....ANY parent who has ever lost a child, and most folks who have had to endure any catatrosphic loss of a close loved one, will tell you two months is nothing. I am horrified at the number of articles I read by doctors or psychologist who suggest that antidepressants should be considered in the case of grief. One person I know whose husband died suddenly and catatrophically was put on THREE psychiatric meds, including an antipsychotic, like grieving that kind of loss is a mental illness??? Many books written by regular folks (and celebrities) who have had to endure terrible grief say exactly what Stephany wrote: if you medicate your grief, it will still be waiting there for you to endure it down the road.

gewisn said...

Who are all you people to declare that someone else's grief should not be medicated? How come YOU get to decide? When evaluate a patient, I describe for him the benefits and potential risks, and the alternatives, including "do nothing right now, and we can re-evaluate again in a few weeks." Silly me, I was thinking that the patient gets a big say in what we do about this situation.

Stephany said...

"Who are all you people to declare that someone else's grief should not be medicated?"

I am one, and I am a grief survivor, who chose not to use medications, to deal with the feelings and raw emotions, instead of dumbing it down with drugs.

It's my choice, and thankfully I have one.

gewisn said...

Stephany,
That's right. You get to decide. It's no more up to me to decide you should be medicated than to decide you shouldn't. Your doctor should provide a recommendation, an explanation of the risks/benefits, the alternatives, and then let YOU decide.
I see pt's every week who are about to give in to suicidal thoughts/plans and are begging for pharmacologic help in addition to psychologic help.
Who am I to deny them this help because some academic says "grief should not be medicated." It's my job to explain it to them and help them make an informed decision, which includes my recommendation based on training and experience.

Joel Hassman, MD said...

I am going to reply here, because I read Gewisn's comments to be contradictory. In one statement the author says, "Silly me, I was thinking the patient gets a big say in what we do about this situation [depression versus bereavement-?-the author is vague here]", and then later "It's my job to explain it [?-again, just meds or multiple options] to them and help them make an informed decision...".

Well, what is the informed decision, and how do you allow them to have a say? Take meds or not? Be in therapy first or then look to meds? Accept a diagnosis of depression versus bereavement, and what is your criteria of when bereavement has become complicated?

By your standards, as loosely related here, any patient who verbalizes suicidal thoughts is in need of meds? Gee, would you go to funerals and offer meds to those grieving who might be entertaining those thoughts in the midst of early grief? I.e, most of the participants who are directly impacted by the loss?

Come on, am I the only doctor who sees a lot of colleagues recommending medication when a patient complains they are hurting from a death in their life? I certainly see a lot of these people come in and complain that is all the intervention they were offered, unfortunately more often by non-psychiatric providers who do not know any better to think of advising see a therapist or find a support group for grief therapy.

I will not just sit idly by and listen to providers sell this quick fix mentality further. When bereavement becomes depression, I will not deny people options that are indicated for that level of mood disturbance. I just ask this of colleagues: do you take the time to fully assess whether a patient is depressed per the stigmata that medication can have an impact, or, do you pull out the Rx pad after the patient says "I'm depressed".

Personally, I find this trend depressing!

Dr John said...

gewisn seems to misunderstand that no one is saying his friends complaints were "some fantasy". His complaints are known only to his friend and no one else. He may have pain that is not always correlated to elevations of amylase and lipase but only he knows this when he has pain. Perhaps not every attack, but panceatitis is a disorder consistently correlated with objective laboratory and CT findings unlike ANY psychiatric dx ever. To compare it as a syndrome with those found in DSM and claim the two are in both in support of "syndrome" based DX seems to miss that they are far more different than alike. If I go in tonight to the ER complaining of belly pain I will not get a DX of pancreatitis just because I do complain. I could go into any psychiatrist's office in the country and complain of symptoms of MDD regardless if I have them or not and get the DX. Having a Dx of pancreatitis actually tells you something objective about the problem. Not everything but something. Having a Dx from the DSM tells you nothing with any objectivity. Psychiatrists seem to insist they know more than they actually do and get mad when you point out they do not really know much at all besides jargon. I am a psychiatrist.It's an empty paradigm but I admit I am ignorant which is not very sexy.

gewisn said...

Dr Hassman is CORRECT.
Rx-ing does happen all too quickly from many providers.
If I implied something opposite to Dr Hassman's main point, then I apologize for my poor writing.

My point is that each pt deserves my full attention and discussion of the treatments available, and it is not appropriate for any providers to decide a priori that all pt's in grief should NOT be medicated. It is just as incorrect and dismissive to decide that all such pt's should be denied medication as it would be to medicate all of them. (Although I never meant that Dr Hassman suggested they should all be prevented from getting medication, others did.) My point is that there should be no "knee jerk" responses in either direction. THIS patient's situation needs to be evaluated carefully and the risks/benefits in THIS situation elaborated.

Suicidal thoughts/plans DO make me think about using all the tools at my disposal - but that does not mean that it automatically results in an Rx. I never wrote that it does, nor do I think that was a fair inference from what I wrote. But obviously, the severity of the symptoms/suffering and the potential consequences of foregoing a reasonable treatment must be weighed in EVERY case. When there are suicidal thoughts/plans (or even gestures/attempts), then the urgency of the potential consequences begins to rise rapidly, and must be weighed into the decisions involved. In fact, the vast majority of the literature on the subject indicates that a recent loss INcreases the risk of suicide. Now PLEASE do not take that to mean I'll medicate or hospitalize everyone who's had a loved one die recently, even if they have Suicidal thoughts. But any reasonable psychiatrist will admit that those two things should enter into the weighing of risks/benefits of a number of treatment options.

Now, as to the article about DSM-5 changes:
I don't think that having the grief exclusion in or out will make much difference to inappropriate prescribing practices. Those who are careful about prescribing will continue to be careful, and those who are not - well, their just as unlikely to change their practices.
This is about Quality Control in medicine, and the DSM is really not capable of addressing that.

Anyway, thank you for the opportunity to engage in the conversation.

Thai said...

Do antidepressants even work for bereavement? Or is it one of those non-linear things where some forms of bereavement respond to medications in some patients but other forms and other patients do not, etc..?

And if the answer to this question is "yes"- i.e. that it is non-linear- and a physician cannot tell where a patient is on the non-linear bereavement response scale, then even through no fault of their own, still one must ask: "what is the economic value we are providing our patient?"

Why couldn't the patient just try the medications themselves after typing into a computer "yes" or "no" responses to potential exclusion criteria questions?

Are we also not required to justify our own economic value to the clinical transaction?

Indeed, if you read gewisn's response closely, it suggests that if he/she is a psychiatrist then he/she is really implying that at least some of the med prescribing that he/she does can be done by someone/something else at much lower cost.

... I might remind many that regardless of personal political views on health care, what no one denies is the notion that cost of care plays a role in mortality. Are we playing a role in this?

Adding "value" to a clinical encounter is one thing. But what if "we" don't?

Has that value been "quantified"?

Stephany said...

I totally agree with informed consent, and that include much more information than the average package insert from the drug companies.

Stephany said...

Re: the timeline of grief and death:

The typical length of grieving goes an 18 month course, anyone who has taken a basic psych class knows that it has stages, and each person goes by their own pace...so with that in mind, with regard to "how does a doctor decide to offer meds?" for grief, then a doctor simply thinks to self, how long has this patient been grieving? and to what extent does the grief appear to be causing dysfunction in regular routine? has the person stopped working? etc.

IF a patient is not allowed to go through the proper amount of grieving time before medication is added, this could hinder the healing process, by squashing down the feelings that need to be processed.

Also, considering SSRIs have black box warnings of suicide thinking, as a possible side effect, this can complicate things, which then the medication roulette begins, where another med is added to counter another side effect, etc.

I believe doctors decide how to run their practices and their prescribing habits are their own choice long before any KOL in the DSM-5 talks discussed how to treat (medicate vs. non medicate) a patient.

The solution to throw medications at emotionally-based symptoms is just another way that shows how medicated this society has become, based on a paradigm instilled by pharmaceutical companies.

Also, of course psychiatrists do base their practice on medications, so asking for therapy in that setting might not work, unless the patient understands their doctor and how they use medications in their practice.

I believe patients and doctors should have a discussion on belief of meds etc before taking one another on in that professional relationship.

Ronald Pies MD said...

I appreciate the thoughtful comments of several colleagues, but I would like to reply to a few misunderstandings regarding my own views on depression and bereavement.

Dr. Arpaia believes that my position, and that of the DSM, “…is that a symptom complex is a diagnosis regardless of the environmental factors [and] bereavement is the example in [Pies’s] article.” In truth, I would never make such a broad argument.

If, by “environmental factors”, we include physical aspects of the environment, there are certainly cases in which the “symptom complex” of a major depressive episode would not lead to a diagnosis of major depressive disorder [MDD]. For example, if a patient were exposed to two weeks of low levels of carbon monoxide in his home, and presented with two weeks of low energy, poor concentration, depression, etc, he would likely not receive a diagnosis of MDD, either by DSM “rules” or by my own diagnostic principles.

This is because we have good empirical reasons to believe that acute depressive symptoms secondary to an “environment” of carbon monoxide have a different course, outcome, morbidity/ mortality, and response to treatment than does “idiopathic” MDD. So, too, with depression secondary to hypothyroidism, HIV-AIDS, steroid toxicity, etc.

In contrast, there are no controlled studies showing that bereavement—or any other kind of loss--significantly alters the patient’s clinical course, symptom picture, morbidity/mortality, or response to treatment, assuming the patient meets all symptom and duration criteria for MDD. That said, such a loss may certainly influence the focus of psycho-therapy, “grief work”, and treatment planning.

There is also very little evidence to support the widely-held view that antidepressants will “interfere with” or “numb” the grieving process, and therefore should not be prescribed, even when the grieving patient meets criteria for MDD. On the contrary: in a recent study by Hensley et al (J Affect Disord. 2009 Feb;113(1-2):142-9),the authors found that “…escitalopram improved depressive, anxiety, and grief symptoms in individuals experiencing a major depressive episode related to the loss of a loved one.” Note that both grief symptoms and depression improved. This was a small, open study, but the results were consistent with those of Zisook et al [see Zisook et al, J Clin Psychiatry. 2001 Apr;62(4):227-30.] who found that, “Major depressive symptoms occurring shortly after the loss of a loved one (i.e., bereavement) appear to respond to bupropion SR. Treatment of these symptoms does not intensify grief; rather, improvement in depression is associated with decreases in grief intensity.”

To be clear: most patients who experience a major loss will not meet full MDD criteria, and I do not consider grief or ordinary bereavement “disorders” that require professional treatment. I would certainly never recommend antidepressant treatment for uncomplicated grief or bereavement. Moreover, contrary to Dr. Hassman’s conclusion that I believe “…bereavement should be quickly lumped into a depressive diagnosis…” I have repeatedly pointed out that ordinary or “productive” grief and major depression have many striking phenomenological differences not captured by DSM symptom checklists [http://www.psychiatrictimes.com/display/article/10168/1523978?verify=0]

I would strongly urge colleagues who want to pursue these issues to read the excellent review paper by Zisook and Shear [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691160/] as well as the important study by Corruble et al, showing that use of the DSM-IV bereavement exclusion may actually “backfire” and paradoxically select for “sicker” depressed patients [see J Clin Psychiatry.2009;70: 1091-7]

Ronald Pies MD
[Disclosure statement at www.psychiatrictimes.com]

Joseph Arpaia, MD said...

I am not sure where Dr. Pies gets the idea that the effects of CO exposure are any more "biological" than the effects of losing a job. The patients social environment affects their biology and the DSM seems to ignore this more as time goes on.

The biology of someone who meets criteria for MDD with no stressors on Axis IV is likely to be very different from someone who meets critera for MDD after a job loss. I would actually diagnose the latter with Adjustment Disorder with Depressed Mood.

The treatments and response rates are different too. At least in my practice.

Dr. Pies states "there are no controlled studies showing that bereavement—or any other kind of loss--significantly alters the patient’s clinical course, symptom picture, morbidity/mortality, or response to treatment, assuming the patient meets all symptom and duration criteria for MDD"

This supports my point that the DSM is not scientific. It is not possible to do a prospective randomized controlled study on the effect of breavement or other loss on the aspects he mentions of MDD. To do that you would have to take a large group of people, separate them into similar groups and inflict a major loss on the subject group. You would then compare the people in that group who got depressed with those in the control group who got depressed.

Clearly this can't be done. Therefore the question that the DSM "answers" by lumping bereavement together with depression is not a question that can be investigated scientifically.

I'm sure the authors used retrospective studies to support their conclusions. But retrospective studies are not science. Too many "findings" about health discovered by retrospective studies have been discovered to be false when tested in prospective studies, HRT for example.

My point is that the DSM is not scientific. I base my conclusion on the fact that it is not possible to run rigorously controlled studies on mood in a human population. If someone thinks this is not a fact then prove me wrong.

In the absence of science people use belief to arrive at conclusions. This is not wrong. Its the best we can do.

Referencing Dr. Pies' comment at the start of this discusseion. The DSM-5 is a Rorschach pattern, not just for society, but also for the authors who are projecting their hopes, fears, loves, ... . That is not wrong either. What is wrong is the claim that it is scientific.

--Joe

Anonymous said...

I'd really like to ask: do antidepressants "work", period, under any circumstances for any diagnosis??? Seems to me there's a fair amount of evidence that they don't work, at least not much better than placebo. I know plenty of people who swear they've been helpful, but when I read the study data, it makes me think it's more about placebo effect. And then there are the pesky problems with side effects and withdrawal difficulties. And, I agree, to the acutely bereaved, most docs seem to prefer to whip out the Rx pad than talk about how challenging grief is and other, non-Rx options to endure it. And I don't think it's "academics" saying you shouldn't medicate grief ... I think it's mostly grief survivors.

gewisn said...

Dr Arpaia,
By your reasoning, all of astronomy is devoid of science because we cannot do prospective randomized controlled studies on distant planets and stars. Prospective RCT's are not the only science. It may be our best way to remove as many biases and confounders as possible - but it is not the only science.

SteveM said...

Re: Dr. Arpaia - "The biology of someone who meets criteria for MDD with no stressors on Axis IV is likely to be very different from someone who meets critera for MDD after a job loss. I would actually diagnose the latter with Adjustment Disorder with Depressed Mood."

Perhaps not Dr. Arpaia, but I suppose the archetypal psychiatrist would prescribe an anti-depressant in either case. So what does it matter if the patient suffers from MDD or Depressed Mood if the treatment modality is going to be the same?

Which by extension, begs the associated question. What is the need for a complex DSM, when psychiatric practice is being constrained to psycho-pharmacological solutions across the continuum of disorders?

Maybe psychiatry should drop the charade of diagnostic accuracy (and therapeutic relevance) and reduce the DSM to the indications associated with the inventory of psychotropic drugs.

Providers could then refer to the "DSF" (Diagnostic & Statistical Folder) which would contain marketing brochures from the Pharma reps.

S said...

"For example, if a patient were exposed to two weeks of low levels of carbon monoxide in his home, and presented with two weeks of low energy, poor concentration, depression, etc, he would likely not receive a diagnosis of MDD, either by DSM “rules” or by my own diagnostic principles."

Okay, i understand what you're saying here, Dr. Pies, and my comment is going to be entirely irrelevant to the point at hand...

I'm still compelled to comment on your specific example (even though the example itself was beside the point), because in practice, do you really think it would occur to a psychiatrist to rule out carbon monoxide poisoning? I have been hospitalized for depressive-like symptoms, and when i mentioned that i was being exposed to smoke constantly on the job (prairie burn season; we had an early green-up which led to a month of working in thick black smoke), it was dismissed by the social workers and taken by the psychiatrist as evidence that i was hiding something or trying to manipulate him... I left with an axis 2 BPD diagnosis because i had refused to tell him what was "really" going on in my life.

S said...

What is the rationale for categorizing grief-related disturbances (unmitigated grief requiring treatment, or whatever you call it) as a type of mood disorder rather than adjustment disorder? I understand the adjustment disorders are being reclassified, too.

(Thank you for your patience! I realize that i am way out of my league in much of this discussion.)

Thai said...

Who pays for "informed consent" that you say needs to be much longer than a package insert?

We are not even sure meds work. We are not sure meds should be used. We are not sure who the meds should be used on even if they do work and now on top of all of this you say you want lots of information to make a informed decision when all the information we have says "we can't answer"???

And who do you expect to give you this "I don't know" information when we really do not know what we are doing?

And who pays for this person to do something with highly questionable value?

And why do we do it? Just because you want us to do it? What you say goes above all others?

Do we cut school budgets even more to pay someone to spend the time to tell you "we just don't know" or do we keep others from affording their blood pressure medicines so you can have that conversation?

Make no mistake, whether it is depression or bereavement, the patient is just as much a part of the problem in the whole "what is the right thing to be done" quagmire as the drug companies and physicians are.

And this gets me depressed!

Anonymous said...

Dr. Pies, not that I would wish for you to experienced a loved ones death to try out an SSRI. But frankly, I am tired of psychiatrists minimizing side effects who have never taken these meds.

I was on meds prior to my a close relative dying two years ago. They numbed my grief. As I have slowly tapered off of them, I am experiencing delayed grief.

I can definitely say that what Stephany said is true.

Dr. Hasman, thank you so much as one who has experience the numbing of my grief emotions thanks to meds for what you said.

Anyway, I pretty disgusted by the "let's medicate every human emotion come heck or high water mode". I realized that meds are called for in desperate situations so please don't make me out to be an anti-med zealot.

But as one who is experiencing delayed grief thanks to these "wonderful" meds, to want medicalize bereavement is beyond belief.

AA

Dr John said...

This is a wonderful debate and Dr Carlat should again be thanked for providing us this blog. The debate itself in particular the issue of what if anything should be done to/with grieving people along with people who's sexual behavior or substance use or lack of attention or whatever we see in them we are not comfortable with or they complain of is the core of why psychiatry fails and always will fail to be anything close to medical science. Debates about what constitutes an elevated cholesterol do not involve our core personal beliefs.What psychiatry/psychology can never acknowledge is that it has not and is not capable of coming up with a core set of principles on what the best way to live is. This is obvious in its hx of creating disorders and the DSM based on varying opinions of what is a pathology based just on those varying opinions and nothing else at all(homosexuality). Someone believes grief is to be accepted and must be worked through while someone else sees it as just suffering to be eliminated regardless of meaning with meds.Drs are not allowed to tolerate suffering regardless of meaning so most medicate. This is not a debate about what we see in front of us or a scientific model we disagree on. It is a debate about simply how we value what we see. One reason I never advise anyone to ever see a psychiatrist despite being trained as one is because as a group they seem to have lost any ability to recognize this which has turned them from either useful or dangerous philosophers to mostly just pathetic pill pushers. Meds may help some short term or not perhaps but that is not really why society is interested or debates the DSM or rightly mistrusts psychiatry. I do not see SSRI's being one bit different than scotch or weed or anything else that blunts emotion. I spell that out for people as well as the risks and make them decide but never play the bullshit role that almost everyone in this field does which is that they know anything about what is happening to the person in front of them.The sad fact is there is absolutely nothing of real substance behind the field of psychiatry for the most part. Almost all of what psychiatrists have come up with is of interest to psychiatrists but has no application for those who seek help.There just is no meat on the bone of psychiatry so I end up passing out copies of "The Meditations" to anyone who can read out of desperation.I have listened to these debates for 20 years and we are not one bit closer to resolving any of them because they are arguments about personal values.Sure I know there are issues of value in something as cold as physics but this is way different and everyone knows it. Issues of how people should deal with emotional suffering are not the same as the periodic table or a kidney and we should just stop pretending they can ever be looked at in the same way.Until then we will all be trapped in debates like this.

Stephany said...

Thai

You're right, demanding information on a topic where not many people understand how the drugs work or why, and based on a drugs based treatment paradigm, psychiatrists have a tough time explaining things for true informed consent.

Being a mental health advocate inside the state institution and other locked psych wards, talking with dozens of patients over the last 5 years, and in an acute situation with a 22 yr old daughter who was misdiagnosed and medicated without informed consent, I DO understand your frustration.

Who pays? the tax payer does, the patient does, the doctor does, everyone pays into a system that offers little to no help in dire situations, we see a revolving door happen in psych wards due to these medications not being as efficacious as warrented by the drug companies.

I DO expect doctors to explain what they can via what information they have, to tell the patient facts about the drugs they are being given, in fact it is a patient right in the psychiatric hospital, and due to my daughter being non verbal, and mostly losing her ability to read now, her information was read to her out loud by the doctor and nurse, while I was present.

Informed consent is a right, and a duty for the doctor, so the patient is well aware of side effect possibilities. You would be surprised how many patients do not research their medications, and how many end up with side effects, such as diabetes and many times doctors did not tell them this could happen (talking antipsychotics here).

I agree, with others that this is a good discussion, and I appreciate Dr.Carlat posting my comments.

Joel Hassman, MD said...

Dr Pies is quick to say I am over responding to his position, and yet he talks of two studies utilizing medications, while one for Depression as a diagnosis, the other for "major depressive SYMPTOMS after the loss of a loved one".

Seems to me a quick retort to defend the use of meds for a psychosocial issue, even if the symptoms resemble depressive stigmata. I think you validate my concerns, sir. My colleagues by in large are not ready to step back and reappraise their role in mental health care as just pill dispensers. Colleagues with an academic or publication role seem to think that the status quo is just fine. Well, it is not to those who work on the front lines, to any and all looking for such opinion.

And the DSM 5, as currently being submitted, is just more of the same as to adhering to the party line. Well, as one established psychiatrist who is not an APA member and not a subscriber to the lame adage "if it ain't broke, don't fix it", it is time to realize that maintenance is an ongoing process and sometimes we as a profession make mistakes and need to acknowledge it and rectify it. No one is perfect, right!?

To risk pissing off the old guard of psychiatry, you need to stop being so patriarchal and realize that the whippersnappers have some validity to challenge you! This ain't the 1950's, even 1960's, so you don't know better than me just because you have practiced longer!

Hey, just an opinion!

Joseph Arpaia, MD said...

To gewisn: You are correct. There are fields of science, like astronomy or geology, where RCT's are not used. However, the context here has been medical science and I had assumed that in my comment. There may well be a way of doing medical science without RCTs, but that is not the current paradigm.

I think we will need to come up with a way of doing science in medicine without RCT's to answer many of the questions facing us.

Ronald Pies MD said...

Thanks to colleagues for the stimulating responses!

Recently, the British Science Council spent a full year developing a definition of “science.” Their work-product is succinct and yet radically
insightful:

"Science is the pursuit of knowledge and understanding of the natural and social world following a systematic methodology based on evidence."

For readers who are interested in why psychiatry is, and will remain, a science--whatever the merits or demerits of the DSM process--you can find my blog on this subject at:

http://www.psychiatrictimes.com/display/article/10168/1529320

Best regards, Ron Pies

Dr John said...

No offense to The British Science Council or Dr Pies but saying "Science is the pursuit of knowledge and understanding of the natural and social world following a systematic methodology based on evidence." would qualify the television program "Ghost Hunters" as a scientific endeavour. His description and theirs of psychiatry as science is less compelling than those guys running through old buildings after ghosts. Just saying something is science does not make it good science. I would suggest after reading Dr Pies blog those same readers read some Popper, Kuhn, Foucault or the recent work of Niall McLaren "Humanizing Madness" for a far more convincing argument of why just making up constructs and accumulating data on them is and always will be just "junk science".

Stephanie Jewett, RN, MBA said...

Wow - very good post and discussions - I have known several people that have had medication to help with grieving - I'm sure everyone is different and, if your doctor is on top of things, he/she will mention the benefits, risks, etc. Stephanie

Wendy Burnett said...

As a patient, my concern is that the 30 minute diagnostic interview and 15 minute medication management sessions allowed by most insurance companies leave no time for even the most thoughtful and compassionate doctor to learn ANYTHING about me.

With that type of "treatment model," I worry that the patient becomes no more than a list of symptoms, and the DSM becomes a "cookbook" used to determine a "recipe" of medications used to control those symptoms, with no regard for environmental factors or individual needs.

FunPsych said...

What I'm most annoyed with is that schizoaffective disorder is still in the DSM-5 and it's not more helpful than it is now. It may even be worse. See the link for more details.

Debra said...

Wow, thanks to Thai for introducing me to this blog where people are really thinking and discussing !
(It's so rare these days...)
NOT thanks to Thai for finding me ANOTHER site where the Internet is going to consume me body and particularly soul.
I am a former clinical psychologist who gave up on the doxa, the jargon, etc., AND my practice. I now "work" at my best on an Internet "self help" forum (for free, too !).
Since I am at my best as a generalist, here goes :
WHY oh WHY must psychiatry be a SCIENCE to enjoy prestige and legitimacy ?
Freud already mired himself in this problem.
He instinctively sensed the dangers of reducing the psyche to the object of scientific method speculation, and the problem with making psychoanalysis a traditional science transmitted as a body of knowledge.
His difficulties and observations remain intact today for those interested in the history of our professions.
Umm...
Why make a diagnosis ? Just what does a diagnosis achieve in the interpersonal relationship with the patient that constitutes "treatment" ? To the extent that a diagnosis is ALSO a judgment (of value at the same time that it is a judgment of existence) it creates certain separations that also have THEIR disadvantages.
Diagnoses do not only "reassure" patients (and insurance companies) about what patients "have".
They reassure DOCTORS and other specialists that such specialists DO NOT "HAVE" what their patients "have".
Dangerous assumptions in my book.
The diagnosis trap sets up a hierarchical situation in therapy. This has its advantages and its disadvantages. Many of the advantages are on the side of the... doctors, not the patients.

Joel Hassman, MD said...

Re Debra's above comment: what makes a diagnosis? A direction to pursue treatment; even if the original diagnosis is wrong, then at least you rule out something.

The issue with DSM, at least to me, is not the process, it is the content, and with the intent of DSM 5, it is overkill! My colleagues are getting so desparate to stay employed, they are willing to diagnose a bad day as a disorder!

And, there has to be hierarchy in therapy. If a patient accepts a belief they are equal to the provider, then the process is skewed and the patient will not pursue change as instinctively when working with a director or collaborator, one with the expertise to educate and advise.

Which is why the internet is failing medicine by in large. People think they read something, it infers expertise and knowledge.

But, thank you for your comments and interest to participate here.

a board certified psychiatrist.

Anonymous said...

Dr. Hassman, I had the greatest success working with a therapist who saw herself as equal to the patient. She was very uncomfortable if I put in her in the one up position.

It doesn't mean that she easily let me off the hook but she definitely didn't see herself as better than the patient.

I am not sure what you're trying to say. Of course, you went to medical school and most of your patients probably didn't. But that doesn't make physicians better than us just like I am not better than someone lower in social and economic status than me.

As far as the "evil" internet, without it, I would haven't had a successful taper off of a psych med cocktail.

Anyway, I do have a DSM comment. Folks might want to go to http://alison-bass.blogspot.com/2010/03/financial-conflicts-and-other-problems.html and read the part about why Asperger Syndrome is being phased out for autistic spectrum disorder.

The reason may be "drumroll please" due to financial gain. Don't you all die of shock now, you hear.

AA

AA

Joel Hassman, MD said...

Per anonymous's above comment:

All I will say is this: the point of most psychotherapy is for the therapist to engage with the patient and help work through dysfunction and discord, which is why the patient is in the process in the first place? If you as a patient are looking for a relationship that makes you equal to the provider in the room, then why pay for the service, just find a friend or family member who will be impartial, unbiased, and objective to your issues.

Get the point now?!

I am tired of the rationalizing and minimizing of mental health treatment. If there are treatment processes that provide the interaction you are looking for, more power to you, no pun intended. If you had a therapy experience that had no inequalities to the interaction, this is an exception to me. And, it is not about power by the therapist, it is about maintaining a process that has hierarchy, which occurs in a lot of interactions we have in this culture that are healthy and proper when maintained.

Frame the transference as a power issue, I just hope it leads to return to function and healthy choices.

As per your comment about "...physicians being better than us(patients)", I can't speak for any other doctor, but I can say this: I am not better than other people just because I have an MD title after my name, but, I will not accept people who go on the internet and then come in my office and claim they know as much as I do just because they read some bit of information off a web site. I will listen and respect their position, but, there are too many people who think they are doctors now just because there are sources of information at sites. I don't expect you to understand my position, but, I hope colleagues do and think about what is presented in the office at times. Expertise is learned and crafted, not just read in books or at internet sites.

My position about the internet is from years of experience. Sorry if you do not agree.

Debra said...

Hmm...
For info my psychiatrist husband receives GOOD labor union publications from his psychiatry union which go into the thorny problem of... illegally exercising medecine.
As a FORMER psychoanalyst, I noticed that MD's had some PROBLEMS with the idea that LAY PEOPLE could possibly be as competent exercising psychoanalysis as their M.D. counterparts. (For info, you don't have to be an M.D. to practice psychoanalysis in France.)
Let's look at the larger issues involved.
Should we say that "democracy" is unfolding more and more in our western societies which are still functioning with the relics of the Ancien Regime ? (governors "grace" death penalty offenders under an ideology that goes back to divine right monarchy.)
As democracy continues to unfold in our societies, hierarchical configurations OF ALL SORTS will be increasingly challenged.
Democracy is unfolding with an increasingly DEMOCRATIC access to information, over the Internet too.
I have given up my "hierarchical" comfort to "practice" AS AN EQUAL with people who are having difficulties. And this is building... COMMUNITY.
I am not as sure as many of you seem to be that the YEARS that I spent training QUALIFY ME to claim any kind of cut and dried "knowledge" about the "direction" of treatment.
What direction ?
You... roll with the punches. You learn to take things as they come.
Because that's what LIFE is all about anyway.
Another thing. I don't... JARGON. I know the jargon, but I refrain from using it. (And, by the way I probably don't know YOUR jargon on this blog anyway, the way you don't know mine, over here.)

Dr John said...

The end of this is a fascinating discussion and as I have posted, at the heart of why psychiatry is a dubious paradigm. I like all psychiatrists have had lots of training but there is no indication from the mountains of science that exist on psychotherapy that levels of training alter outcomes. You cannot systematize and then teach human interaction. There are limited exceptions in regards to CBT training but machines and books do that as well as people. Dr Hassman is correct in his description of the dynamic between teacher and student which is what is supposed to take place in psychotherapy. Where I suspect I disagree with him is that psychiatrists in general have anything to offer the world on how people should live there lives or deal with problems anymore than bartenders or priests do. Sure we study a long time but you can study the bible a long time and learn lots of things. That does not mean you know one more real fact about God than the person who has never read it. Priests and psychiatrists suffer from the same problem. They are entrenched in pseudo-knowledge and confuse it with really knowing something about the real questions that are important. Pts can get into arguments with psychiatrists about the best way to have a "therapeutic" relationship because it is not a matter of technical expertise but of value. I doubt that same person would be arguing with a jet pilot on how to fly or a cardiac surgeon on how to cut as these are actual areas of technical expertise and there is almost none of that in psychiatry which is why we argue about its basic premise.

Debra said...

One of the reasons that I gave up my practice, Dr John was that over here in France, Lacanian psychoanalysis is being promoted as "subversion du sujet", that means a revolution in thinking designed to liberate the patient from erroneous beliefs about himself and the world.
But... this kind of revolutionary practice is being conducted by analysts who will not stay in anything under a 4 star hotel (well, lots of them. Not all. Let's be fair.). That's kind of... HYPOCRITICAL.
No way you can be revolutionary while staying in 4 star hotels. (Paid for or not by big pharma.)
Somewhere along the line psychiatry AND psychoanalysis start looking NORMATIVE.
And normative means that you're promoting the social body's agenda for human behavior OVER whiat is in your INDIVIDUAL patient's interest.
You may BELIEVE that you're a scientist.
But... you're really a MORALIST.
Hey, some priests probably do EXCELLENT "therapy" with their constituents. For free, too...
Another gritty little detail : the day that a psychoanalyst from my psychoanalytic association responded to my saying that I really didn't understand why I had to PAY her to say what I was saying (she was ambiguous in setting up an "appointment" with me..) she promptly dissolved and melted in front of me, sputtering out "but how am I going to LIVE if you don't pay me ?"
All capital letters on that one for the intensity effect.
Yeah, just HOW are we going to put the meat and potatoes on the table at night if we don't make people pay for us to listen to them ?
The priests did NOT have that problem...

Joel Hassman, MD said...

Again, I am tired of the rationalizing and minimizing of my profession. My training is equivalent to what a bartender can offer in a tavern? Dismiss my 4 years of residency because I can't put everything I do in the office under the "objective microscope" of these naysayers above?

Where are you in this dialogue, Dr Carlat? Silence is interpreted as acceptance, last I checked.

I am not the typical "silent, Freudian, everything is a countertransference matter" psychiatrist. I happen to feel I have to fight for my career. So, while others may just want to sit on the sidelines and think they'll get their win by just being on the team, people of substance and integrity pay attention to who plays and makes the effort.

Which doesn't come in a pill, does it?

Dr John said...

It has been said that it is very difficult to get someone to believe something if their paycheck depends on them believing the exact opposite.I think Debra's story about an analyst's breakdown reflects part of the problem but it runs much deeper than just money. I think Dr Hassman's response gets to the point. People believe things for all kinds of reasons. One of them is that they have sunk loads of time into training or research which results in them looking at the world a certain way and buying into certain claims of authority based on that effort.This conclusion is often quite wrong and the hx of science is filled with wonderful examples of people who have spent entire lifetimes convinced they were right based in part upon their investment and work, and they were just plain wrong. Homeopathy, Wakefield and MMR/autism link come to mind in medicine as does Lysenkoism. Read the life story of Walter Freeman the father of the lobotomy.To confront the possibility that your religion, or work or world view may be wrong if you are deeply invested in it is just not something most people can do without a complete emotional meltdown. I nearly had one when I realized I could no longer incorporate either the dogma of my Roman Catholic upbringing or Psychiatric training into my observations of the world around me.When you realize you can no longer explain anything or have an effective means of intervention the result is very unpleasant emotions humans wish to avoid. My observation of psychiatrists is that without question, such training no more ensures proper advice about the problems that many people end up seeing a psychiatrist for than bartender training does. I have seen many pts given drugs that did more harm than good and made far worse by reductionary psychiatric DX.I would have to say that as far as even being emotionally stable they are some of the worst role models I have ever encountered and I would trust almost none out of the hundreds I have known to give me any advice in life. That does not mean that always happens or that psychiatrists are not capable of helping people. That is not the question. The question remains: does psychiatric training impart a special knowledge that facilitates this helping of others as psychiatry claims? I see no objective indication of this nor do I find explanations given by psychiatrists which are mostly just claims to authority particularly compelling.I would say the same of priests. This has been a very difficult position for me to take because it requires that after preparing for 8 years and doing 4 years of residency I must admit in most regards, I am no better than a bartender and in some I am worse as I only know how to make a few cocktails.

Debra said...

It appears that there are major differences in the way that we perceive our "mission" towards our patients.
I am 53 years old, my husband 57. I did all of my professional training in France, not in the U.S., during a period where Freudian and Lacanian psychoanalysis had an important influence on all "psys" offering treatment to patients. Psychiatrists and psychologists, as well as psychoanalysts.
It would be interesting to exchange over these very important differences in the way we perceive our therapeutic "mission"....
For the record, I am definitely NOT an "scientific" objectivist, in any sense of the word.

SteveM said...

Re: Dr. John

I can see how a crisis of faith can lead someone to a complete meltdown. Because the metaphysical loss goes to the core of the individual's belief system. But a professional "crisis"? Not so much. I mean if you do something professionally and eventually realize that it doesn't work, you move on to something else.

I am not a psychiatrist. But what I don't understand is why psychiatrists who lose faith in the normative practice paradigm, don't just simply adjust their therapeutic methodologies so that they are aligned with what they as physicians think are the most efficacious forms of treatment.

There appears to be a bunch of alternative paradigmatic approaches already in place. From the radical rejection of mental illness as an illness by Thomas Szasz to the holistic treatment paradigm of Dr. James Gordon. So there are alternative therapeutic archetypes across the non-normative continuum.

I understand the angst of the psychiatrists that reject the drug-centric model of psychiatry as being corrupted. (Because I agree with that assessment.) But the professional process question I have is, why recycle the same issue over and over? Why not step away from the self-induced Stürm und Drang and just modify your treatment paradigm and practice another way?

Dr John said...

Steve M: I have done that in some respects moving my practice to limited approaches I feel have merit but the problem is much deeper than that. You grossly underestimate the similarity between a crisis in faith and a crisis in belief of an entire paradigm. I am not just talking about if I buy into Freudian analysis or Biological Psychiatry and deciding to change from one to another. If you stop believing in an all knowing all caring providential God of the Christian faith do you think you just become a Jew or a Muslim instead? I do not even buy into the premise psychiatry is founded on. It started with the myth of Freudian analysis and that anxiety was at the heart of all psychopathology. This could be cured through talking and bringing unconscious conflicts to the surface. The therapist had special knowledge. Well that's bullshit and so are all the other special schools of psychotherapy as "special knowledge". I don't believe there is hardly anything unique or special that psychiatry or psychiatric training imparts on individuals and watching people get and give it for 20 years has convinced me of this although there are limited exceptions. You want me to just "change my TX paradigm". There is no valid change to make within the paradigm. As I have said it does not prohibit me from trying to help people as human beings. People respond to authority and I will try to help them. I see people made better by religious belief. This does not prove Jesus came back to life and ascended into heaven. Once you quit believing in Santa Claus you can't just believe in the Easter Bunny instead as a truthful alternative.

Debra said...

Steve M suggests that psychiatrists (and other psy professions) can separate out "metaphysical" belief systems and "professional" belief/practice.
This idea assumes that we can conveniently compartementalize our souls to turn on "work" mode in the office and "metaphysical" mode... WHEN ?
The psychiatrist is NOT a doctor like other doctors.
The psychiatric hospital is NOT a hospital like the one where you get your appendix taken out in.
(I hope the people writing on this blog will grant me that, at the very least...)
Current paradigms may operate (lol) under the assumption that it is possible to rationalize psychiatry to resemble other areas of medecine, but this is NOT true in my book.
Trying to pretend that it is, is counterproductive. Particularly for patients.
What you call the transference in English is constructed around, and based on, a belief system.
That's why the psychiatrist's beliefs are... so very important in psychiatry.

Joel Hassman, MD said...

Re Steve above:

You are right that people should step away and modify if the status quo does not work. But, what if no one will pay for your expertise, because it involves asking the patient for work, effort, attention, and change. Pills take away that agenda, and everyone is selling it as the cure all.

Right now, I am working as a temp as I am interested to see if anyone else is really practicing what they preach if it is outside the biochemical imbalance model my field has chained itself to. So far, have not been impressed with what I have seen. Too high expectations on my part? Maybe, but, I am a biopsychosocial practitioner, in a land of paradigms lost.

And, this health care deform legislation to pass, it will be the death of psychiatry, mark my words. Because, and pay attention to this colleagues, why pay psychiatrists $50-75 a med check when our illustrious colleagues in general medicine, gynecology, family practice, and nurse practitioners, who accept less a visit and gladly will write scripts from day one for two or more months are available.

We will be doing one of three things by 2014: working state hospitals (for whatever ones are still open), doing forensic evals and staffing correctional facilities, and working in ERs. Yeah, there may be one or a couple of other niches that other providers won't want to fill and dump it on us, but that is the future of psychiatry by the middle of this decade, as things stand.

Cynicism, pessimism, downright dark, I've been labeled these and others. Me, I call it hardened realism, as I am not in denial.

And, nothing lasts forever, hence the false message of the everlasting gobstopper. This DSM pending will probably be the last.

Thai said...

Dr John, I think I see your bid, I concur and will up you 50 cents: the implications of science's first law of thermodynamics- the conservation of energy- become more and more troubling the older I get and the longer I practice.

All thoughts and behaviors MUST be a form of energy; otherwise how could a thought cause you to life your arm of chop wood or get into an argument or kiss another person? And I say this independent of what we all know are little electrical signals flying around our brains.

But most significantly, as energy, a conservation of energy must apply to each and every thought as well as each and every behavior as well as each and every collection of thoughts and/or behaviors or both. If this were not true, all human thought and behavior would potentially be a perpetual motion machine; something I hope you realize is forbidden by our most empirical of scientifically observed laws.

... I hope you see where this is going. If you have not thought about it from this angle much before, I strongly encourage you to do so.


And in the interest of not getting too off topic, if you would like to discuss this more, I would love to chat with you here.

Be well

Debra said...

I am going to comment on one of the comments of the person commenting on the comments...
Yes, and if you read through that first sentence (it is comprehensible, tedious, yes, but comprehensible..) you will get an idea of just exactly WHAT I do not like about the DSM (which I know mainly through hearing my ex colleagues commenting on it, mea culpa...)
That first sentence is a door opening up another door, opening up another door...
The name of the game is "objectivity".
Putting oneself into a position where one becomes an object for oneself.
It can be argued that this is exactly WHAT consciousness IS.
But if this is what consciousness is, it definitely has some definite drawbacks.
Objectifying oneself (which CAN lead to objectifying... OTHERS) is an insurmountable problem.
As I suggested elsewhere in the comments section here, modern psychiatry is constructed on a belief system. (Hey, this is not a bad thing ; every theory is an elaborate belief system... "theory" comes from "theos", which means.. God, right ?)
And.. a theory that professes to NOT be a theory ? (a simple description...), now.. does that keep it from being a theory ? Hmmm.
Belief number 1 : objectifying is the means by which we approach REALITY, and reality is synonymous with truth.
A quick reread of Plato (lol, I am NOT an expert, mea culpa), will give you a grasp on how Plato's vision of an immediate sensorial, everyday world being a pale copy of an ideal, TRUE one has left an indelible impact on the way we STILL see OUR world.
Like.. that other, TRUER world being one that we just HAVE TO attain.
By... being objective, for instance...
I say that objectivity is not possible. Because those doors just keep opening, and THERE IS NO OTHER REAL TRUE world behind there somewhere in cloud cuckoo land.
I got a real true shock the day that I read Les Liaisons Dangereuses (Laclos), and realized that Madame de Merteuil's accountant of her wedding night confirmed what many of my colleagues and I had noticed... objectivation (of oneself...) is the result of trauma.
So... what is the relation between objectivation of oneself and objectivation of others ?
Is there... TRAUMA involved ?
Hmm...
The comment ? " A robot in Freud's likeness" ?? No please. Freud would NOT have been pleased. Not at all.

Anonymous said...

Wendy Burnett,
The DSM is not so much a ""cookbook" used to determine a "recipe" of medications used to control those symptoms" as it is a codebook used to determine which diagnoses are reimbursable by 3rd parties. If it's in the DSM, it's more likely that the doctor can get paid for it. That's one of the reasons the DSM gets bigger and bigger and bigger every time a new edition is published. Apparently the aim is to classify the entire U.S. populace as mentally ill for reimbursement purposes.

Anonymous said...

Every once in a while on this blog, I see posts remarking about how few of the comments are from patients. It is curious to me that there are 5 or 6 MDs, PhDs, and MSWs here that engage each other quite vigorously, but don't give patient comments the time of day. Is this due to a lack of interest in patient opinions and experiences? Self-importance? I just find it interesting since much of the discussion on this blog concerns psychiatrists' lack of interest in their patients as people and their excessive interest in writing prescriptions. The comments on this blog seem to reflect this mindset quite well.