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Dr. Bob is Robert Hsiung, MD,
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Posted by dazedandconfused on December 2, 2004, at 12:06:20
In reply to Re: The artificial nature of psychiatric diagnosis » ed_uk, posted by Larry Hoover on December 2, 2004, at 8:31:05
Posted by ed_uk on December 2, 2004, at 15:29:52
In reply to Re: The artificial nature of psychiatric diagnosis » ed_uk, posted by Larry Hoover on December 2, 2004, at 8:02:43
To Larry, Scott and everyone else,
I do believe that the DSM has its uses. I am not suggesting that we get rid of it! I do feel, however, that it is misunderstood by patients and professionals alike. In some cases it may do more harm than good. Each diagnosis describes a cluster of symptoms which often occur together, yet each diagnosis is not a specific disease. We could construct many other DSM diagnoses based on clusters of symptoms which tend to occur together. The DSM is only really useful to those who appreciate its inadequacies, many people do not. Misuse of the DSM may harm both individual patients and psychiatric research alike. Larry gave an excellent summary of some of the problems which we face.
Regards,
Ed.
Posted by ed_uk on December 2, 2004, at 15:54:17
In reply to Re: The artificial nature of psychiatric diagnosis, posted by ladyofthelamp on December 2, 2004, at 4:37:50
Hi!
Thank you for your post. :-)
I've often noticed than when I have known a person for 5 minutes, their problems seem to fit perfectly into a DSM category, but after I've known that person for 5 hours they don't fit the diagnosis at all! The more you learn about a person, the more individual and complicated their problems become.
Personally, I've received scores of different DSM diagnoses. Describing me as an anxious, obsessional neurotic would provide almost as much information!
Regards,
Ed.
Posted by simcha on December 2, 2004, at 23:29:44
In reply to The artificial nature of psychiatric diagnosis, posted by ed_uk on December 1, 2004, at 8:57:15
As a student in my psychopharmacology class the professor has told us that the establishment has basically said that the DSM-IVTR is obsolete.
They will have a DSM-V coming out in about a few years.
Then, we in the USA are one of the few countries that relies on the DSM system. The neuro-psychologists are lobbying, very powerfully, for using ICD-10 codes instead of DSM diagnosis to put us in line with most countries. ICD-10 is about symptomology and treating symptoms. It will put many psycho-analysts out of business.
However, we will still need psychiatrists, neuropsychiatrists, and psychotherapists because someone will need to treat the symptoms. The current scans do not prove much. Even Dr. Amen's research is being called into question... I suggest you go to quackwatch.org to look him up.
In the next ten years we will see radical changes in how mental illness is seen, diagnosed, and treated. Most likely a multidisciplinary approach will be embraced.
Psychotherapy actually changes brain chemistry. This is because we have found that experience creates new neural pathways and new neurons. When you do psychotherapy well you help the client re-wire their brian so that it functions in a way that is more functional. Of course, not all conditions respond to psychotherapy.
Psychopharmicology is important for those symptoms that cannot be helped by psychotherapy. Also psychopharms can help kickstart people into a different brain pattern that will help them to re-align their brians through psychotherapy.
This is the current thinking in forward thinking schools like mine...
Simcha
Posted by sunny10 on December 3, 2004, at 11:38:38
In reply to Re: The artificial nature of psychiatric diagnosis, posted by simcha on December 2, 2004, at 23:29:44
I already have a label- it's my name. What I NEED is for someone to make me feel better.
To further Larry's analogy, whether or not you tell a car that it needs a need battery- you have to actually FIX the problem in order to make the car run.
Just because some dr gives me a label (which, by the way is scoffed at and replaced by the next dr who thinks HE knows better), doesn't make me feel better.
And, frankly, I don't care whether my problem stems from nurture or nature- I want it to go away...
So there you have it from the patient's (or car's) point of view...
Posted by ed_uk on December 3, 2004, at 14:59:21
In reply to Re: The artificial nature of psychiatric diagnosis, posted by sunny10 on December 3, 2004, at 11:38:38
What do people think?
Ed.
Posted by simcha on December 3, 2004, at 16:24:25
In reply to Re: DSM versus ICD, posted by ed_uk on December 3, 2004, at 14:59:21
I prefer the ICD. Now I'll make my case...
This applies to the USA:
The DSM classifications get used by insurance companies, governmental agencies, other mental health professionals to pigeon-hole clients in nice neat boxes. Once these clients are pigeon-holed, depending on the condition, they may or may not help the client to the extent that they actually need.
For example, if you get a diagnosis of Bipolar Disorder and you want to get private medical insurance because you've been layed-off of a job and you have run out of COBRA, you will not get the insurance or you will be charged at least $2000 per month, which basically amounts to not getting insurance... Also it is on your insurance record for 10-years. So, no insurance company, unless you get another job, will cover your Bipolar Disorder.
Personality Disorders are another difficult part of the DSM. A person labelled with a Personality Disorder will not get insurance. Most clinicians will deny treatment for Personality Disorders because they are seen as "untreatable."
By the way, look in the DSM-IVTR for the diagnosis of Bipolar. It only requires one manic episode for receiving the diagnosis of Bipolar. It does not call for a pattern or cycle of depressive episodes, euthymic, episodes, and manic episodes. Also, the specifiers for Bipolar I are time-based. They are based on the most recent event like a manic or depressive episode. Ask psychologists and psychiatrists if there is any utility to this part of the coding for the diagnosis. None of them will be able to tell you the value of knowing the state at which the person was diagnosed as Bipolar I at the time he or she was diagnosed as such.
So, with the ICD, you have no labels. You only have symptomology. In treatment, in practicality, clinicians are treating symptomology with medication and therapy. You can even use depth-orentied psychotherapy with the goal of treating symptoms.
So, the ICD codes have more use to the clinician because it is more specific. We can see the host of symptoms that the client is presenting. Bipolar I gives me only a general map as to what is possible that my client might be experiencing. The ICD sypmtom codes tell me exactly what the client has to deal with at the moment. You can also track the ICD codes during the course of treatment to predict prognosis better than simply having a DSM dx.
Also, moreover, US medical insurance companies will fight using ICD codes for diagnosing mental symptomology. This is because by US law, they must TREAT ALL ACTUAL SYMPTOMS. Therefore this makes exlusions impossible. Eventually this might force the insurance monster in this country to release its strangle-hold on medical care. It might actually lead to universal health care of some form in this country and bring us up to the rest of the first world in standard of care.
The DSM system fails we clinicians all the time. It blocks us from treating some poeple who need treatment because some DSM codes are covered and some are not. Thus the client cannot come up with the funds to pay for treatment. This is completely unjust and most first world countries find this to be yet another reason to look down on the USA.
So, I'm all for the ICD codes. And I hope the neuropsychologists win so that I might be able to give better treatment to my future clients as a Marriage and Family Therapist.
Simcha
Posted by ed_uk on December 5, 2004, at 3:34:25
In reply to Re: DSM versus ICD, posted by simcha on December 3, 2004, at 16:24:25
Hello......
Thank you simcha for your informative post. Does anyone else have any opinions on the ICD?
Regards,
Ed.
Posted by ed_uk on December 5, 2004, at 5:32:15
In reply to Re: DSM versus ICD » simcha, posted by ed_uk on December 5, 2004, at 3:34:25
Does anyone have any knowledge of other classification systems such as...........
The Chinese Classification of Mental Disorders (CCMD)
The French Classification for Child and Adolescent Mental Disorders
The Latin American Guide for Psychiatric Diagnosis
There's also a Japanese system but I've forgotten what it's called....... but I do know that it includes the diagnosis of Taijin Kyofusho 'a Japanese form of social anxiety centered around concern for offending others with inappropriate behavior or offensive appearance'. Anyone here suffer from that?
It's interesting to look at how culture can influence the expression of mental health problems eg. social anxiety in the West tends to revolve around the self rather than other people.
Ed.
Posted by simcha on December 5, 2004, at 15:29:34
In reply to Re: Other methods of classification eg. CCMD, posted by ed_uk on December 5, 2004, at 5:32:15
Yes, Diagnosis is very cultural. That's another reason to adopt the ICD... It would be classifying symptoms rather than pathologizing say... offensive dress...
Each culture has it's own issues with therapy.
For instance, it is rare to see an Asian client who has been raise in an Asian culture to come in for therapy here in the West. It seems to have to do with their particular concept of shame and that the family helps people with their problems. We westerners tend to be more individualistic and the Asians (in a gross generalization) tend to be more collectivistic.
So, it just makes sense that different cultures would classify mental illness differently or even see things as mental illnesses that other cultures would not.
Simcha
Posted by ed_uk on December 5, 2004, at 18:15:40
In reply to Re: Other methods of classification eg. CCMD, posted by simcha on December 5, 2004, at 15:29:34
Everyone seems to be getting diagnosed with bipolar II at the moment. Do you think that this is a step forward or a step in the wrong direction?
Ed.
Posted by simcha on December 5, 2004, at 23:32:31
In reply to Re: BP II, posted by ed_uk on December 5, 2004, at 18:15:40
I think that BPII will disappear in the DSM IV. Most professionals who are currently working on the DSM IV are uncomfortable with the dx. What exactly is a hypomanic episode? How do you evaluate that?
Simcha
Posted by SLS on December 6, 2004, at 0:55:59
In reply to Re: DSM versus ICD, posted by simcha on December 3, 2004, at 16:24:25
> I prefer the ICD. Now I'll make my case...
>
> This applies to the USA:
>
> The DSM classifications get used by insurance companies, governmental agencies, other mental health professionals to pigeon-hole clients in nice neat boxes. Once these clients are pigeon-holed, depending on the condition, they may or may not help the client to the extent that they actually need.But isn't this really a defect in the way a diagnostic system is used rather than in the system itself?
- Scott
Posted by ed_uk on December 6, 2004, at 5:48:28
In reply to Re: DSM versus ICD, posted by SLS on December 6, 2004, at 0:55:59
Bipolar II seems to be a 'fashionable' diagnosis among psychiatrists at the moment. I think it may be overdiagnosed, especially in people who suffer from chronic depression but have unusual reactions to antidepressants. The problem with the current 'expansion' of the bipolar spectrum is that the term bipolar is at risk of becoming meaningless. The concept of manic-depression used to be quite specific and many people who are currently diagnosed as bipolar would be excluded. Some people see the 'expansion' of bipolar disorder as an advance, I'm not so sure.... the boundaries of bipolar disorder seem to be getting increasingly vague to the extent that if somone tells you that they are bipolar, it doesn't tell you that much.
I think Elizabeth put it well in 2002...
'I still think that bipolar II is probably overdiagnosed, though. I never have a clear idea what people mean when they say, "I have bipolar II disorder." The definition has become vague, the boundaries blurred. Even bipolar I gets confusing when you're talking about mixed episodes, rapid-cycling, comorbid disorders, etc. I'm sure you've noticed how the concept of bipolar disorder has become diluted in recent years.'
Regards,
Ed.
Posted by SLS on December 6, 2004, at 8:28:06
In reply to Re: Bipolar II, posted by ed_uk on December 6, 2004, at 5:48:28
Bipolar II might be misdiagnosed often due to its current fashionability, but it makes it no less a syndrome with well defined boundaries and probably a distinct physiological etiology. I think the differential responses to lithium and valproate help make a case for this. The DSM IV is specific as to what constitutes bipolar II, and describes hypomania as follows:
Hypomanic EpisodeA distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.
During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
inflated self-esteem or grandiosity
decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli)increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
The disturbance in mood and the change in functioning are observable by others.
The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder
- Scott
Posted by ed_uk on December 6, 2004, at 8:52:50
In reply to Re: Bipolar II, posted by SLS on December 6, 2004, at 8:28:06
Hi Scott,
To me, it seems highly improbable that any diagnosis which is based on subjectively measured symptoms will ever be demonstrated to be a distinct physiological entity. Rather, a group of people who's symptoms are consistent with the same DSM diagnosis are likely to have numerous different pathologies- both biological and psychosocial in nature.
Regards,
Ed.
Posted by SLS on December 6, 2004, at 9:43:31
In reply to Re: Distinct Physiological entity, posted by ed_uk on December 6, 2004, at 8:52:50
Hi Ed.
> To me, it seems highly improbable that any diagnosis which is based on subjectively measured symptoms will ever be demonstrated to be a distinct physiological entity. Rather, a group of people who's symptoms are consistent with the same DSM diagnosis are likely to have numerous different pathologies- both biological and psychosocial in nature.
I respectfully disagree. I think whatever physiological heterogeneity there is within bipolar disorder, idiosycratic to the individual, is minor and due to the great plasticity of the human brain. There are enough phenotypic variables such that differential responses to medications for the same illness are inevitable. This is true of many other illnesses as well, including Parkinsons and Alzheimers, disorders with well known and identifiable physiological pathologies.
Clinical diagnosis of somatic illness very often relies upon signs and symptoms reported by the patient that are subjective and must be interpreted by the physician. There are so many idiopathic syndromes for which no etiology has been identified and few, if any physical tests exist. Medicine in these circumstances remains an art and relies on the subjective observations and clinical interpretations of the physician. Gulf War syndrome might be an example of this.
- Scott
Posted by ed_uk on December 6, 2004, at 10:02:36
In reply to Re: Distinct Physiological entity » ed_uk, posted by SLS on December 6, 2004, at 9:43:31
Hi Scott,
>Clinical diagnosis of somatic illness very often relies upon signs and symptoms reported by the patient that are subjective and must be interpreted by the physician.
Yes, many non-psychiatric disorders are ill-defined. Especially the so-called 'functional' disorders such as IBS and CFS. The word 'functional' is often thought of as being synonymous with 'non-organic' but in reality it seems to mean 'not able to identify any definate organic pathology and we don't really know what the problem is'.
You seem very quiet lately. How are you feeling? Would you consider going back on Parnate and desipramine, perhaps combined with Lamictal and/or Abilify. I haven't considered drug interactions there!
Regards,
Ed.
Posted by banga on December 6, 2004, at 10:10:54
In reply to Re: Distinct Physiological entity » ed_uk, posted by SLS on December 6, 2004, at 9:43:31
The truth, as often in life, may lie in between. I dont belive people carrying a specific diagnosis are necessarily homogenous, yet I dont think it's the case that there are many many reasons why a person is exhibiting symptoms of a certain diagnosisand putting them in one category is meaningless. Twins and genetics studies hint at this...for instance, there are hints that there are perhaps two types within the bipolar group--one which is inherited as strictly bipolar, and another bipolar-exhibiting the same symptoms, yet is genetically related to unipolar depression. That is, one type is closely related to unipolar depression and both diseases show up in the family tree, the other is not and is passed on as bipolar only.
One thing to keep in mind when diagnosing hypomania is the clause that specifies that it interferes with functioning and is a DISTINCT DEPARTURE from usual functioning--enough to have people comment on it. Otherwise you can read almost any diagnosis and find elements of yourself in it. Yes, I get irritable, expansive and behave irresponsibly at those times, but does someone from the side say "what the h**?? What happened to her?? Whats going on somethings is suddenly really off. This is not like her."
Not that I am a DSM lover at all, or believe in the lines drawn for/between disorders is accurate...and yet we do need to have some way of defining things. As some pointed out, if you dont, the disorders become so diluted that they lose meaning. Clinicians need someplace to start, and a diagnosis can sometimes be validating and calming--"there is a name for my suffering and I am not alone."
Posted by ed_uk on December 6, 2004, at 10:39:36
In reply to Re: Distinct Physiological entity, posted by banga on December 6, 2004, at 10:10:54
It would be good to hear some suggestions. Here are some examples....
Risks,
1. Stigma eg. schizophrenia, personality disorder
2. May lead to inappropriate treatment due to a 'one size fits all' mentality eg. the prevailing attitude in the UK that everyone with depressive symptoms should be treated with an SSRI, whatever their symptoms.
3. Difficulties getting a job.
4. Tendency to medicalise 'normal' life processes eg. grief.
5. Possible excessive use of medication to treat a 'disorder' when other treatments might be more suitable.
6. Encouraging people to feel that they can't help themselves because they have a 'real disorder.'
7. Shame of receiving a psychiatric diagnosis.
8. Reduction of personal responsibility ie. blaming your disorder for your unpleasant behaviour.
9. May give little information about cause or prognosis.
Benefits,
1. Recognition that other people have similar problems.
2. 'Now my condition has a name I can find a suitable treatment'.
3. A concise way to summarise your problems.
4. Reduction of excessive guilt eg. a woman may feel completely responsible for her husband's depression until he is diagnosed.
5. Getting insurance companies to pay for treatment.
6. Possible reduction in stigma... 'he's not mad he's ill'.
7. Helps people to take mental health problems more seriously if they have a name.
8. Diagnostic criteria useful in research and clinical trials.
9. Developing a common language among psychiatrists.
Ed.
Posted by banga on December 6, 2004, at 11:16:15
In reply to Benefits versus risks of diagnosis in psychiatry, posted by ed_uk on December 6, 2004, at 10:39:36
In terms of many of the risks, some could be resolved with education. Stigma--educating the public. Better, more well-rounded training for psychiatrists. To realize one size does not fit all. (I was so horrified when a young med intern told me he wanted to go into psychiatry--"It is all so simple, just three neurotransmitters to consider." Oh god.) To recognize and educate clients about psychotherapy, alternative approaches. Not to encourage the "I am sick and cant do nothing about it"--but rather encourage a take-charge attitude about a complex, multifaceted condition.
I dont recall how it is in the ICD, but the DSM specifies--you DO NOT diagnose depression if the person is in bereavement-the first six months. And after that if they still exhibit depressive symptoms, its complicated bereavment. So if clinicians followed this guideline--and didnt prescribe meds unless the person is in truly critical circumstances, it would be ok in my book. And the educated clinician would also take into account other factors---culture (some cultures grieve at least a year), etc.In terms of job loss/hiring--ha!! that one will never go away. I suffer major depression and alcoholism (and anxiety) and I am in psychology--but NO WAY would I ever let on about this in my career, even this group of "Understanding" people would not be ok with it.
Again, I have many doubts about diagnoses and as you said there are minuses. But haveing gone through problems with invalidgating comments that hindered appropriate care ("you dont have depression-there is no such thing, you just have alcoholism and are in denial"; or on the other side "you dont have alcoholism youre just depressed". or "there is nothing physically wrong, you just are a hypochondriac and have depression" (when I had serious vitamin b12 deficiency). So even if the names are not perfect and somewhat arbitrary, you have to name it to treat it.
I waver between loving the beauty of a non-black and white, complex world and despising it.
Posted by ed_uk on December 6, 2004, at 11:32:56
In reply to Re: Benefits versus risks of diagnosis in psychiatry, posted by banga on December 6, 2004, at 11:16:15
Hi,
Thank you for your reply. You mentioned being in psychology, are you a clinical psychologist? It's strange not really knowing who you are talking to, whether they are male or female, how old they are, what their name is or what they look like. (Except Scott who has a picture on his website!)
>"you dont have depression-there is no such thing, you just have alcoholism and are in denial"; or on the other side "you dont have alcoholism youre just depressed". or "there is nothing physically wrong, you just are a hypochondriac and have depression" (when I had serious vitamin b12 deficiency.)
.......People are very judgmental sometimes. They assume to know so much about you when really they know very little.
There is something very 'attractive' about the DSMs classification system. I expect that it's highly appealing to psychiatrists with obsessive-compulsive personality disorder!!
Regards,
Ed.
Posted by SLS on December 6, 2004, at 15:18:30
In reply to Benefits versus risks of diagnosis in psychiatry, posted by ed_uk on December 6, 2004, at 10:39:36
Hi Ed.
I know nothing about the ICD. How does it differ from the DSM?
Thanks.
- Scott
Posted by simcha on December 6, 2004, at 23:21:46
In reply to Re: Benefits versus risks of diagnosis in psychiatry, posted by SLS on December 6, 2004, at 15:18:30
Scott,
If you have a DSM IVTR look in the back. You will find ICD-10 codes. It's only a start. It describes treatable symptomology rather than labelling people with disorders.
It's more specific than labelling someone as MDD with Recurrant Features. It can allow psychiatrists, psychologists, social workers, and therapists more freedom to treat symptoms without having to place clients in a diagnostic box.
For Major Depressive Disorder for instance, a clinician can list; depressed mood (time), lack of appetite, erectile dysfunction or less interested in sex, hyper-insomnia or hypo-insomnia, etc. You would have a cluster of symptoms that are more specific. With Major Depressive Disorder not every depression looks the same. The DSM IV does not allow clinicians to differentiate the depression as much as the ICD.
We see evidence in different types of mania, hypomania, depression, hallucinations, etc. on this board. We also see that people with the same diagnosis do not do as well as other people do on specific medications. The ICD might be a way to help psychiatrists tailor medical treatment to more specific symptomology. Also for pscychotherapists we can tailor our treatment plans more specifically too. This is going to really frustrate the American Medical Insurance Machine because they will have to cover conditions they don't cover.
The ugly secret is that sometimes you HAVE to come up with a DSM diagnosis so that clients can use insurance, medicaid, or medicare to pay for their treatment. This forces clinicians to lump people into DSM categories who generally fit the category but might not present with all the symptoms. Also it can keep people from treatment who have only some of the symptoms of a DSM category yet their life is impaire to an extent that they aren't functioning. Insurance, medicaid, and medicare will not allow treatment without a DSM classification. In the future they will be forced to help these people with very real symptoms that impair their real functioning.
So, the DSM IVTR is expensive. If you do not have one and have no reason to fork over $50 then you can go to the public library and look at the end of it. There you will find ICD-10 codes.
Simcha
Posted by SLS on December 7, 2004, at 9:12:46
In reply to Re: To Scott, posted by ed_uk on December 6, 2004, at 10:02:36
Hi Ed.
> You seem very quiet lately.
Yes, I have been. Depression has been taking its toll on my energy and motivation. I also feel stupid as hell. I am vegetative, and my mind is so inactive. I just don't have the brain power to post much. I've lost quite a bit of confidence and self-esteen. Not fun.
I thank you for your concern.
Take care.
- Scott
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