Tuesday, December 15, 2009

Is Psychiatry Now a “House Divided”?

Hired guns.” “Whores.” “Greedy, insensitive bastards. “ These are some of the more printable epithets used to describe psychiatric physicians who (allegedly) have “sold out to Big Pharma” ”—for example, by failing to disclose conflicts of interest, or to report large sums of money earned through their work with pharmaceutical companies. It may surprise some—but perhaps not many—that these terms of abuse were hurled not by members of some anti-psychiatry group, but by psychiatrists, writing on a well-known “watchdog” blog site. To be clear: I have no wish to excuse or rationalize the actions of some in our field who indeed have abused the public trust by engaging in any of the actions described. Anger—even outrage—is appropriate and healthy, with respect to their behavior. But must we also demonize these individuals, some of whom (notwithstanding their transgressions) have made important contributions to clinical care and scientific research?

The late Dr Albert Ellis—the psychologist who originated Rational Emotive Behavioral Therapy—always insisted that we distinguish between a person’s behavior, and the individual’s value as a human being. Writing in their classic 1961 book, A Guide to Rational Living, Ellis and his colleague, Robert Harper argued that, “…A person’s (good or bad) acts are the results of his being, but they are never that being itself.” (Ellis and Harper, 1961 p. 104, italics added).

We often tell our patients they should not condemn the totality of their being on the basis of a selfish or hurtful act they have committed—yet some of us seem all too ready to condemn a colleague in the most sweeping and dehumanizing terms, because he or she is guilty (or is believed guilty) of one or more ethical lapses. By all means, let us condemn the transgressions! But let’s also retain a scintilla of human sympathy and understanding for the flawed human beings who committed them.

The problem of “demonizing rhetoric” is obviously not confined to the field of psychiatry, where it seems to be the effluvium of a few particularly bilious individuals. The language of demonization is all too prevalent in the narratives of many political and religious groups, who attack their opponents as infidels, heretics, traitors, or even worse. Carried to an extreme, we find terms like “vermin” applied to ethnic or religious groups who are the objects of hatred or persecution—the Nazis were infamous in their use of this term. Yes, I know—there is a difference between calling someone a “drug company whore” and reducing the person to the status of vermin. But the distance between the terms is not as wide as some would persuade themselves. And when one moves from the psychiatry blog sites to the rabid anti-psychiatry websites (eg, http://outlawpsychiatry.blogspot.com/), one sees in no uncertain terms how easily an unflattering epithet can morph into a dehumanizing slur.

The divisions within psychiatry extend far beyond concerns over “conflicts of interest” and “Big Pharma”—where there are, at least, valid ethical issues to be raised. Unfortunately, the profession continues to be mired in the same fruitless arguments over “biology” versus “psychology” that anthropologist Tanya Luhrmann documented in her classic investigation, Of Two Minds: The Growing Disorder in American Psychiatry (2000). And, all too often, one hears proponents of the “biomedical” model disparaging advocates of the “psychodynamic” model—or vice verse. This sterile debate persists, despite the heroic efforts of “pluralistic unifiers”, such as my colleagues Nassir Ghaemi, Godehard Oepen, Glen Gabbard, Michael A. Schwartz, and Cynthia Geppert. These clinician-scholars have refused to buy into the Manichean world of the “splitters”; rather, they embrace a scientific-humanistic perspective that comprehends both molecules and motives. This broad-based, pluralistic model was the one I imbibed during my residency at Upstate Medical University, where a fledgling resident could —as my teachers, Robert Daly and Eugene Kaplan might put it—“do theology in the morning and biology in the afternoon.” Oh, yes—and engage in heated but respectful debate with gadfly Tom Szasz, during lunch!

Psychiatry as a profession faces many challenges, and no small number of genuine threats. From excessive involvement with “Big Pharma” to the diminished role of psychotherapy; from managed care’s fifteen minute “med checks” to controversies over DSM-V, psychiatry understandably feels besieged, these days. No doubt, we have contributed to many of these problems through our own missteps or inaction. Yet, for all its flaws, psychiatry remains the most comprehensive and humanistic of the medical specialties— and has a great deal to offer the suffering individuals who seek our help. In 1858, Abraham Lincoln—addressing the issue of slavery-- warned the nation that, “A house divided against itself cannot stand.” It would be a genuine tragedy if psychiatry becomes “a house divided” by the rancor of its own rhetoric.

Ronald Pies, MD

"Every kingdom divided against itself is brought to desolation; and every city or house divided against itself shall not stand."-- Matthew 12:25
“Judge the whole of the person charitably.”—Talmud (Pirke Avot, 1:6)
Read more!

Monday, November 30, 2009

“Psychosurgery”: Promise, Perils, and Patients’ Protection

Psychosurgery. For some, the word connotes all the promising therapeutic applications of modern neuroscience; for others, it connotes all the baneful excesses of unregulated pseudoscience. In his recent front page story for the New York Times (Nov. 27), Benedict Carey presented a balanced and nuanced view of what is sometimes termed “psychiatric neurosurgery,” focusing mainly on cingulotomy, capsulotomy, and other neurosurgical approaches to refractory obsessive-compulsive disorder (OCD).

For one of the patients interviewed by Carey, neurosurgery to treat her intractable OCD was clearly very helpful; yet for other patients, neurosurgery for their OCD had adverse behavioral effects despite some improvement in their obsessive-compulsive symptoms. Thus, in one Swedish study by Ruck and colleagues, only 3 of 25 patients with OCD undergoing capsulotomy were in remission without adverse effects at long-term follow-up. Ten patients “were considered to have significant problems with executive functioning, apathy, or disinhibition” after their procedures.

Psychiatric Times has discussed both the medical and ethical issues surrounding psychosurgery, pointing out both the need for better understanding of the underlying brain circuits targeted by psychosurgery and the imperative of safe-guarding the rights of potential candidates for psychosurgery. One conundrum noted by Dr. Christian Ruck, and cited in the Times article, is that “innovation is driven by groups that believe in their method, thus introducing bias that is almost impossible to avoid.” This is not to impugn the humanitarian motives that underlie most instances of psychosurgery; it is merely to say that institutions that perform psychosurgery may have a vested interest in seeing and presenting their outcome data in the best possible light.

In addition to the need for very strong informed consent procedures and intra-institutional review boards, there is also a case to be made for outside, independent review of an institution’s psychosurgery program. Indeed, in the U.N. General Assembly’s statement on the protection of persons with mental illness, we find the following injunction:

“Psychosurgery and other intrusive and irreversible treatments for mental illness shall never be carried out on a patient who is an involuntary patient in a mental health facility and, to the extent that domestic law permits them to be carried out, they may be carried out on any other patient only where the patient has given informed consent and an independent external body has satisfied itself that there is genuine informed consent and that the treatment best serves the health needs of the patient."

Given the rarity of psychiatric neurosurgery—the Times noted that about 500 such procedures have been carried out in the United States over the past decade—review of each case by an independent neuropsychiatric expert outside the “provider” institution seems feasible. There is no doubt that for some suffering patients who have not responded to standard treatment, psychosurgery may be the only viable option. But as Alan Stone, MD concluded in his article for Psychiatric Times, "Given the historical burden of the old psychosurgery, the new neurosurgeons have a special obligation to proceed with utmost scientific caution."

Ronald Pies, MD
Editor-in-Chief Read more!

Thursday, October 29, 2009

Rape and the Heart of Darkness at Richmond High

The press reported it in various ways—either as a “brutal gang rape” or, more forensically, as a “2½-hour assault” on the Richmond High School campus. Anyway you look at it, the horrendous attack on a 15-year old girl raises troubling questions for theologians, criminologists, and, of course, psychiatrists. How do we understand an act as brutal as rape? What factors and forces in the rapist’s development can possibly account for such behavior? And how on earth do we explain the apparent indifference of the large crowd that watched the attack in Richmond, California, and allegedly did nothing to stop it—or even, to report it?

In a thoughtful analysis on CNN, Stephanie Chen provides a range of “expert opinions” on this last question. Essentially, the various hypotheses asserted that:
o Bystanders in large groups are unlikely to take appropriate action in such cases, because they assume others have already done so; or because “doing nothing becomes the norm” (the so-called bystander effect).
o Witnesses who otherwise might have phoned 911 may have feared retaliation from the perpetrators.
o Bystanders do not feel a “bond” with the victim, and may actually identify with the perpetrator, who is perceived as “more important” than the victim.

The CNN report speculated at length on the so-called “Genovese Syndrome,” named for the woman stabbed to death in Queens, NY in 1964, supposedly after 38 witnesses to the attack did nothing to help her. (The facts, however, are almost certainly otherwise, as an article in American Psychologist argues.)

Most of the forensic experts quoted in the CNN piece took a predictably “objective” point of view. None ventured the opinion that the crowd at Richmond High School failed to aid the rape victim because many human beings often act in a selfish, callous, and cowardly manner. Nobody put forth the view of rabbinical Judaism; namely, that we are all born with 2 primal inclinations, constantly at war with one another. The “good inclination” (yetzer hatov) is usually held to be a kind of late “add-on” to the more powerful “evil inclination” (yetzer hara), which often gains the upper hand. The yetzer hara seems to have been alive and well at Richmond High—and nobody lifted a finger to stop it. Rabbi Bruce Kadden, however, points out that the yetzer hara is not some “devil” external to our own selves; rather,

“…the yetzer hara is very much a part of us. We therefore cannot deny personal responsibility for what the yetzer hara causes us to do. It may explain our behavior, but it does not excuse it.”

Many psychiatrists, it seems to me, have been reluctant to venture into the obscure headwaters of evil—the territory explored so vividly in Josef Conrad’s 1902 novella, “The Heart of Darkness,” Many in our profession have taken the “scientific” view that matters of good and evil are best left to theologians and clergy; and that clinicians should limit themselves to analyzing and correcting the developmental, biological, and psychological precursors of “anti-social behavior.”

I disagree. Psychiatrists and other mental health professionals should not avoid the issue of evil, if only for the reason that good and evil are very real, and matter very deeply, to most of our patients. A woman who presents in therapy with a rape-related traumatic syndrome may be said to embody the problem of human evil: even her physiological responses to trauma-related stimuli have been altered by her experience. But more than that, the patient (male or female) who has suffered a brutal assault may need to explore the moral dimensions of the act and its consequences: “How could another human being do such a horrible thing? And - - why me, Doctor? Was I being punished by God? Am I somehow responsible for what happened? What should I do with all the hatred and rage I feel toward this monster? Is it right that I want him to suffer as much as I have?”

These understandable questions do not arise for all victims of trauma; but when they do, psychiatrists must be prepared to engage the patient in a serious, “I-Thou” dialogue, to use Martin Buber’s term. Similarly, philosopher and ethicist Margaret U. Walker has written of the need for “moral repair” after an act of wrongdoing. As therapists, we help effect such repair by establishing trust—the first step in mending the torn fabric of the traumatized patient’s moral universe. To gain the patient’s trust, however, we must be ready to talk frankly about good and evil. Sometimes, this means confronting the enormity of acts such as those that occurred at Richmond High.

[UPDATE 11/06/09]

It seems there may be a bright spot to this horrendous story, after all. ABC News is reporting that, while nearly all the bystanders did nothing,

"...one woman called police as soon as she heard what was happening. The 18-year-old mother and former Richmond High School student was at home watching a movie when her brother-in-law came home and said he had seen a girl getting raped.

"He was like, 'I'm scared,' and I'm like, 'Well, we should call the cops because that's the thing to do,'" Margarita Vargas said. "I didn't think about it twice, I just, I'm like, I immediately grabbed the phone and said, 'I'm gonna call the cops,' because that's something I wouldn't want anybody to go through or if I was in that situation, I would want someone to do the same for me."

Vargas said after making the call to police, she walked over to the school to make sure the police had arrived."

Ronald Pies, MD
Read more!

Tuesday, October 27, 2009

On Narcissism, the Internet, and Social Networking Sites

I read with interest the posts of Dr John Grohol, PsyD regarding my commentary, "Twitter and YouTube: Unanticipated Consequences of the Self-Esteem Movement.I had hoped it would bring attention to this topic and am glad that this has opened up an important dialogue. However, the author has missed the point.

It was not my intention to blame the internet for creating more narcissists or for causing irreparable harm to our children. In fact, nowhere in my article do I “demonize” the internet as this post asserts. It is my contention that the internet is not, in and of itself, inherently evil. I do not blame social networking sites for the rise of narcissism in our culture. A more careful reading of the piece would reveal that I consider social networking sites a symptom of a narcissistic society rather than the cause of it.

My argument was not that the internet is to blame for the sad state of affairs in which we find ourselves. Rather, it is the philosophy that influenced the rearing of an entire generation, namely, the self-esteem movement. By shielding our youth from the dangers of criticism and disappointment, they have arrived at adulthood without having developed the coping skills they need to survive in the real world. No one succeeds at everything. This is a fact of life. But the millennial generation was not exposed to this reality. Not only do they shun criticism, they feel entitled to praise, even if undeserved.

The studies of Twenge and Campbell[1-3] have shown a steady rise in narcissism in the past several decades. While the author is quick to point to statements he believes are not backed by data, he fails to even take note of this study. This rise in narcissism was evident before the advent of social networking sites. And it is my contention that these sites would not have risen to such prominence but for the fact that a generation of narcissists needed an outlet. The millennial generation needed a way to assert their uniqueness, their specialness and garner the attention and praise of the masses. Facebook, MySpace, YouTube and Twitter filled the bill.

Communication has certainly changed throughout the last century. And with each successive change, the degree of face to face contact has decreased. From in person visits and hand written notes, we have progressed to phone calls and emails. Each time we remove ourselves from face-to-face contact with each other, the communication becomes eroded. When we can see each other, we can appreciate important non-verbal cues, absent if we just speak over the phone.

When we write or email, we lose the information that can be gleaned from pauses, prosody, and intonation of speech that are still available over the phone. When we text or blog, we have none of those things. The words must stand alone and they are condensed to their most basic and, in some cases, completely replaced by shorthand such as “lol”and “omg.”

Call me old-fashioned, but having a close friend with whom I have shared real experiences and confided real feelings to beats being anyone’s “bff.”

Lauren LaPorta, MD
Chairman, Department of Psychiatry
St Joseph's Regional Medical Center
Paterson, NJ

1. Twenge JM, Campbell WK. “Isn’t it fun to get the respect we’re going to deserve?” Narcissism, social rejection, and aggression. Pers Soc Psychol Bull. 2003;29:261-272.
2. Twenge JM, Konrath S, Foster JD, et al. Egos inflating over time: a cross-temporal meta-analysis of the Narcissistic Personality Inventory. J Pers. 2008;76:875-928.
3. Twenge J, Campbell K, Trzesniewski K, Donnellan B. Narcissism in Gen Y: is it increasing or not? Two opposing perspectives. Twenge J, Campbell WK. Generation Me in the jury box. The Jury Expert. May 2009;21(3). http://www.astcweb.org/public/publication/article.cfm/1/21/3/Narcissism-in-Generation-Y-and-Litigation-Advocacy. Accessed September 4, 2009.
Read more!

Thursday, October 22, 2009

A Citizen Above Suspicion

When I thought of writing this letter, I was put in mind of Jean-Jacques Dessalines (1758 – 1806), the Emperor of the tiny nation of Haiti, writing to the most powerful man of that time, Napoleon Bonaparte. Like Dessalines, I am a grain of sand standing next to the huge mountain of the psychiatric establishment. Fortunately, there is Psychiatric Times (PT), which allows a "half-island nation" like me, and many others, to reach a wide audience. Some publications welcome opinions only from the “Napoleons” of our profession!

I am trying to say that PT is "a citizen above suspicion." Its fairness is beyond question and the integrity of its editorial board, rock-solid. Still, your editorial, "Conflicts of Interest: Policies of Psychiatric Times" is the necessary spark that should ignite a long-awaited discussion. Given that PT's opinions are free of unethical influences from commercial sponsors, I want to ask Dr Pies and Ms Kweskin to explore the other side of the "coin" that they have just tossed: does the psychiatric establishment show fairness in its review of dissident opinions regarding non-pharmacological issues, such as psychiatric diagnosis?

My own experience says no. With the exception of PT and the Journal of Affective Disorders, few psychiatric journals will publish unorthodox opinions—for example, those questioning the validity of DSM diagnoses such as Borderline Personality Disorder, Oppositional-Defiant Disorder, or the widespread notion of “Treatment-resistant Depression.” By the same token, many in this specialty consider it heresy to suggest that ADHD is not as prevalent as the establishment wants us to believe. Similarly, the psychiatric establishment resists suggestions that many cases of "comorbid" anxiety and depression are neither, but are actually cases of sub-threshold bipolar spectrum disorder: the so-called "anxiety" is in fact agitation secondary to the bipolar mood disturbance.

I think there is real fear, within the psychiatric establishment, of opening a Pandora’s Box that could bring about a complete overhaul of the most revered diagnostic dogmas in this field. I very much appreciate the fact that PT allows dissident readers to raise their voices against such entrenched orthodoxy. Often, it is not a case of “crying wolf”-- but of the wolf actually scratching at the door.

Manuel Mota-Castillo MD

I want to thank Dr Mota for his kind and appreciative remarks concerning Psychiatric Times. We have a long tradition of allowing "dissident" voices and controversial opinions to be heard in our pages (paper and now, electronic). Our founding Editor-in-Chief, John Schwartz, MD, never shied away from taking on "the powers that be," or in confronting the misbehavior of some groups opposed to the field of psychiatry.

I do suspect that there is resistance to change among some representatives of the psychiatric "establishment" (although, to be candid, some might place me in that camp). I think there are many reasons for this. One is that once a scientific (or not-so-scientific) "paradigm" has been established (to use historian Thomas Kuhn's term), it is hard to challenge it, even with persuasive data. The DSM framework is such a paradigm, and there is understandable reluctance to move away from it on the part of some who have labored mightily to create it. I suppose we should not completely discount the role of "Big Pharma" in promoting some diagnoses--perhaps including ADHD--for obvious reasons, though I do not take the view that all pharmaceutical companies are driven only by the profit motive. Still, the "direct to consumer" advertising so common these days may have the effect of reifying or expanding some diagnoses, even in the absence of convincing evidence. On the other hand, I do not agree with the camp that points to "disease mongering" as the source of, for example, the increased recognition of bipolar spectrum disorders.

I also think that some dubious diagnoses, such as "Conduct Disorder", simply reflect our over-reliance on a purely descriptive (symptom-based) diagnostic framework, rather than on one that seeks to establish common biogenetic and phenomenological (experiential) factors that may underlie several seemingly diverse conditions. Another good example, in my view, is the push to reify "Internet Addiction" as a full-fledged and discrete disorder, when it may represent merely one manifestation of an underlying aberration in the brain's reward system.

So, thanks, Dr Mota, for your voice of conscience and concern!

Ronald Pies, MD

Read more!

Friday, October 16, 2009

Monitoring Pharmonitor

Congratulations to Dr Alan A. Stone for taking the time to nail the bias contained in the Supplement discussed in his piece, “Reality-Checking: Case In Point.” And congratulations to Psychiatric Times for printing Dr Stone’s article. Perhaps PT is ready to take further steps in separating itself from the "educational efforts" sponsored by pharmaceutical companies that have so deeply corrupted the practice of psychiatry, and medicine.
Chuck Joy, MD
Erie PA
Read more!

Thursday, September 17, 2009

On integrity and never ending diagnostic updates…

I read the article by Dr Frances and was impressed by its intelligence. I then read the response by the APA in the person of Dr Schatzberg et al. I was shocked by its sleazy attack on Dr Frances’ integrity. Dr Frances was accused of arguing because of anticipated personal financial gain. The accusation that Dr Frances was arguing ad hominem was the pot calling the kettle black.
The whole business of never-ending updates and changes to our diagnoses—whether paradigm-shifting or minor—should remind those of us who need reminding how primitive is our knowledge in our specialty.
Dr Frances seems more aware of this than Dr Schatzberg et al.

Arnold Knepfer, MD
Read more!

Wednesday, September 16, 2009

Toward mental illness for all?

We were surprised to read of the open letter by Drs Frances and Spitzer regarding the creation of DSM-V. Over time we have been puzzled by a succession of Diagnostic and Statistical Manuals, and have been forced to conclude the long-term purpose of the DSM is to abolish mental illness from American society. Currently only half of all Americans fit the criteria in DSM-IV to be diagnosed with one kind of mental illness or another. 1 Surely the goal of DSM-V must be to increase the percentage of Americans eligible to be mentally ill. With the inclusion of sub-syndromal categories in DSM-V, the total percentage of mentally ill Americans should reach 75-80%. With a long-term commitment by the American Psychiatric Association to DSM-VI --or, if necessary, DSM-VII - - 100% of the American population can eventually be declared mentally ill. On that glorious day all mental health practitioners can take satisfaction in their decades long quest to abolish mental illness, because, as we all know, when everyone has something then no one has it.

1.“Mental Illness in U.S. Presidents Between 1776 and 1974,” J. R. T. Davidson, K. M. Connor, and M. Swartz, The Journal of Nervous and Mental Disease. Read more!

Thursday, September 3, 2009

This Accusation Has No Logic. . .

The APA DSM-V Task Force’s response to Dr. Frances’s critique of DSM-V noted that his royalties for DSM-IV products would cease when DSM-V is published. However, Dr. Frances’ critique called for DSM-V developers to make fewer changes- - not more, and he made no call for longer DSM-V field trials; in fact he proposed additions such as prodromal and subthreshold syndromes to be put in an appendix that called for further research. His critique then would not extend his receipt of royalties, and perhaps even shorten them. Thus, the APA has no logic to accuse him of financial incentive unless they opine that his critique could significantly delay publication of DSM-V somehow, eg, by inciting turmoil within the working group which would mean that a critical mass of people would agree with his logic.

Doug Berger, M.D., Ph.D.
U.S. Board-Certified Psychiatrist
Tokyo, Japan
Read more!

Preserving Irrelevance?

I agree with Drs Schatzberg, Scully, Kupfer and Regier. In my busy clinical practice, I do not see DSM-IV doing justice to clinical reality. Less than 25% of my patients have a genuinely good syndromatic fit with specific DSM diagnoses.

With diagnostic criteria strictly applied, I find myself with numerous NOS diagnoses with little in terms of treatment or prognosis utility. Preserving the current DSM structure would make it increasingly irrelevant to clinical practice.

DSM-IV seems to misconstrue how psychiatric diagnosis is made in real-world clinical situations which seem to parallel GK Chesterton’s famous quote “you can only find truth with logic if you have already found truth without it.” While a paradigm shift may be clearly disruptive, that is what psychiatry needs at this juncture to keep classification relevant to day today clinical practice.

While advances in neurobiology may help resolve some of our diagnostic stalemates, the complex sequential interaction between neurobiology, changing adaptive demands, and existential issues may continue to make psychiatric diagnosis a moving target.

Although a literature review seems to be an important avenue in the DSM revision, we must not overvalue it because we could easily get sidetracked by a circular situation in which literature is based on classification and vice versa.

Prevesh Rustagi, MD
Read more!

Wednesday, September 2, 2009

Members of the International Public Are Also Disappearing into a DSM Black Hole

In response to Dr. Johnson’s post, “Like Writing a Letter to Santa Claus,” UK Patient Advocate Suzy Chapman notes that Web-based platforms like Wiki and Facebook are likely to be viewed as little more than token nods in the direction of transparency and stakeholder participation.

[Note: Comment slightly edited from original.]

In June of this year, I raised inquiries with the DSM-V Task Force in relation to the APA’s participation in the World Health Organization’s (WHO) International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders which were passed on to the APA’s Media Relations office.

I was first quizzed on whether I was a member of the press and then whether, as a patient advocate, I was working on behalf of a specific organization. I was told that before the APA was to provide answers to my inquiries, I was to disclose my plans for this information and whether I intended to publish responses. The basis on which these inquiries were being made was duly supplied to the APA’s Media Relations office.

Six weeks down the line, no answers have been forthcoming. Following several gentle prods for a response, I was told that the APA’s Media Relations office “had responded to [my] many other inquiries” and that “the information is available on the DSM-V Web site.”

Since not one query has been answered, since the information requested is not available on the APA’s DSM-V Web site, and since APA’s Media Relations office has declined my request to resend any response they may have already issued, one can only conclude that the APA is seeking to obfuscate the issue.

Similarly, the WHO has embraced new platforms such as wikis and Facebook as part of its own revision process towards ICD-11, in order to facilitate communication and participation by professionals, users, and stakeholders in the ICD-11 development process. But plain, old-fashioned written inquiries relating to the lack of meeting summaries; the provision of a list of members of the ICD-DSM Harmonization Group (which isn’t apparent from the WHO’s Web site), and clarification of what is (or will be) the channel of communication for interest groups wishing to communicate with, or submit proposals to, the new TAG (Topic Advisory Group) for Neurology are being ping-ponged between various key WHO steering and advisory group members. Again, no answers are forthcoming, and there appears to be some difficulty in identifying who is mandated to address such inquiries.

In September 2008, former DSM Work Group Chair Robert L. Spitzer, MD compared the “transparency” of the WHO with that of the current DSM revision Task Force: “It should be noted that in contrast to this new APA confidentiality policy, which discourages DSM-V members from providing information about the ongoing revision process, the World Health Organization has adopted the opposite policy with regard to its development of ICD-11. Minutes of all ICD-11 meetings are posted on the WHO website without any restrictions on who can have access...”

In practice, the WHO would not appear to be publishing minutes of all its meetings on the WHO website other than summary reports of the first 3 meetings of the Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. Coordinator Dr Geoffrey Reed has yet to publish a summary of the Advisory Group’s last meeting held in Geneva 9 months ago. So I would question Dr Spitzer’s view.

Inquiries from members of the public are also disappearing into a DSM black hole.

Suzy Chapman
UK Patient Advocate
Read more!

Tuesday, September 1, 2009

On Integrity and Never Ending Diagnostic Updates…

I read the article by Dr Frances and was impressed by its intelligence. I then read the response by the APA in the person of Dr Schatzberg et al. I was shocked by its sleazy attack on Dr Frances’ integrity. Dr Frances was accused of arguing because of anticipated personal financial gain. The accusation that Dr Frances was arguing ad hominem was the pot calling the kettle black.
The whole business of never-ending updates and changes to our diagnoses—whether paradigm-shifting or minor—should remind those of us who need reminding how primitive is our knowledge in our specialty.

Dr Frances seems more aware of this than Dr Schatzberg et al.

Arnold Knepfer, MD
Read more!

Like Writing a Letter to Santa Claus

A reader sent us a note regarding his experiences in providing feedback to the DSM-V committee:

"I responded to the chance to upload to the DSM-V website an article I published with suggested DSM-V criteria for addiction - perhaps 6 months ago. There was never a response. My comments went off into cyberspace. I had my administrator try to follow up with a call to the head of the DSM-V committee, Charles O'Brien, MD. No response. So while it is true that there is a way to “give input,” there is no evidence that anyone on the DSM-V committee I wrote to ever saw the input. It was like writing a letter to Santa Claus at the North Pole.

Brian Johnson M.D.
Director of Addiction Psychiatry
SUNY Upstate Medical University"

How do you feel the DSM-V committee should handle feedback? Should a more public "sounding ground" be offered, such as a forum or Facebook?

Check out our DSM-V page for updates!
Read more!

No One Owns Us, No Matter Who Has Sold Us

Thank you Dr. Frances for making explicit what has been an implicit, sad trend in our profession. I also believe we have slowly sold out to the pharmaceuticals. Perhaps, first, it was to legitimize ourselves as part of "real" medicine. I could have lived with the psychiatry of twenty or even ten years ago. The pens, dinners, and drug samples did not pose any heart-wrenching ethical dilemmas for me or any colleague I knew. But these past ten years, there's been a creeping toxic alliance between big business (insurance, big pharm) and our professional elite. And this sell-out has nothing to do with plastic perks. We have invited the drug companies to dictate our theories and diseases and support our research for answers that sell their products. The only folks who don't recognize this as self-serving and transparent are us.

The overselling of pharmaceuticals by psychiatric "spokes-professionals" has saddled the hard-working private Docs with the credibility gap of a used-car salesman. That's why people are running to alternative medicine. Given the recent news, why shouldn't someone wonder if we’re hyping meds to "guarantee" repeat business?

And what about the quality of our own professional life? We're left with a field that chokes on creativity and once embraced innovations. Now, anyone who does not march to the drum-beat of evidence-based medicine risks censure, although the limitations of this model have been extensively exposed.

I agree with Dr. Frances that classifications used by practitioners should be created or at least informed by them. We are the professionals who have a grasp of those who get ill. Those who conceptualize patients in terms of significant deviations and benign to severe symptoms will not know them, nor see obvious truths. Right now, one obvious truth is people are angry with us and it's not a part of their diagnosis. They need to trust the integrity of professional they see. How can they, given the above? Would we?

What Dr. Frances describes is a nightmare - new diseases to pathologize more of "normal" life that will need more medication. Throw in electronic medical records and no one will dare go to us, for fear of being branded with a four digit code. (Yes, I mean that allusion. How many readers remember our protests to Soviet psychiatry?)

I agree with Dr. Frances that the DSM, our "Bible" implies more than metaphorical weight. We need to think carefully now. What we define as illness also implies what's healthy. This "Bible" will imply that those who do “adapt" to our stressed-filled, detached, and achingly competitive lifestyle are adjusted. Since many of us share that life, we may not want to look at it too closely.

Do we agree? If you are over 40, you have witnessed a rocket acceleration of changes in how we live. During this time, our profession has adopted a complaint posture, one that accedes to conformity, going with a flow and being on top of it. We don't think to buck it, anymore. And the flow now is materialism which dictates that cost-effective is a synonym for "right" and "best." We have been instrumental in promoting that equation so we should ponder the truth of this, at least a little.

And unless we get totally discredited by our more ambitious colleagues, like it or not, we psychiatrists are still the "Priests of Normality. If we take our role with any gravity, we might ask ourselves whether the lifestyle we endorse as "normal” really nurtures healthy.

Whether or not you believe we have sold out to big pharm, whether or not you think medications are the answer for all ills are no longer important. As Dr. Frances implies, there are bigger "fish frying" and more than our professional integrity or power at stake.

The past ten years, our profession has joined hands with big business and politicians and marched an increasingly materialistic road, from the medicine we practice (in which personality is reduced to DNA and neurotransmitter concentrations) to the values that guide us (bottom line bucks.) Meanwhile, we are bleeding soul and courage, words that will never be found in any DSM, ever. But we know them and feel a gnawing void when they are not present.

Maybe we got so entrenched in materialism for the same reasons our culture did. That doesn't mean we have to remain so. As "Priests of Normality," we could concern ourselves with making "normal" more humane, rather than "making" a DSM that makes mental illness more pervasive. We could use the credibility we have left to make businesses more family-friendly. We might have more healthy children. We could focus on people empowering themselves to take charge of their out-of-control lives. Why should we push pills to "help" people adapt to what's making them sick? We could change the focus of who we are. We could stop being prescribers.

No one owns us, no matter who has sold us.

Peggy Finston MD
Prescott, Arizona Read more!

Wednesday, August 26, 2009

It's About Time!

In a 138-page report released on Wednesday, August 5th, the American Psychological Association said that there is little evidence to suggest that efforts to change a person's sexual orientation from gay or lesbian to heterosexual are successful. In fact, such efforts can cause harm. The findings of the American Psychological Association Task Force of Appropriate Therapeutic Responses to Sexual Orientation indicate that efforts to switch a person's sexual orientation through psychological interventions can lead to loss of sexual feeling, suicidality, depression, and anxiety.

The task force reviewed the literature on 87 studies that were undertaken from 1960 through 2007. They found serious methodological problems with the majority of the studies. The few studies that were methodologically strong showed that lasting change was rare. Judith M. Glassgold, chair of the task force said that "contrary to claims of sexual orientation change advocates and practitioners, there is insufficient evidence to support the use of psychological interventions to change sexual orientation...."

At the annual meeting of the American Psychological Association, the Council of Representatives passed a resolution that urges mental health professionals not to recommend change of sexual orientation through therapy or any other methods. Homosexuality was removed from DSM in 1973.

What is your experience in working with the gay, lesbian, and transgendered population? Should the American Psychiatric Association be producing a similar review of treatment with this population?
Read more!

Skepticism Remains but They'll Give it a Shot

The New York Times recently reported that the US Army plans to provide intensive mental stress training for its troops. In an effort to reduce potential mental health problems such as depression, posttraumatic stress disorder, and suicide, the US Army will require that all active-duty soldiers, reservists, and members of the National Guard undergo stress training. The training will also be available to family members and civilian employees.

There is still some skepticism about whether the program will be effective--it is modeled on techniques that have been tested mainly on middle school children--or whether the training is really needed. The army's chief of staff, General George W. Casey Jr, said that many in the military consider talk of emotion to be a sign of weakness. "I'm still not sure that our culture in ready to accept this [emotional resiliency training]."

The primary objective of the program is to teach resiliency. The training draws on recent research that suggests that people can manage stress by thinking in terms of their psychological strengths. Ultimately, the goal of the training is posttraumatic growth.

It seems that more troops these days are returning with a greater degree of mental health problems. Does anyone know if this is really the case? Or are we just hearing more about it than in the past? Why do you think there is such a high prevalence of problems for returning troops and their families? Is it because the nature of the wars we are fighting has changed? Read more!

Monday, August 10, 2009

Gone But Not Forgotten: Remembering and Learning From the Events at Camp Liberty

Thank you Psychiatric Times for your eulogies to the fallen mental health workers and patients at Camp Liberty last month ("Death of Psychiatrist and Other Soldiers Triggers Inquiry Into Military's Mental Health Care", July 2009). Dr Houseal and Springle were truly dedicated humanitarians and patriots. I extend my condolences to their families and the families of the fallen patients as well.

I am a psychiatrist at a VA Clinic stateside. We are anxiously awaiting the onslaught of returning veterans who struggle with mental illness and posttraumatic stress disorder (PTSD).

Existing studies regarding PTSD and our knowledge from working with Viet Nam veterans and Gulf War Veterans elucidates our failures more than our successes. The foremost is the failure to learn from our mistakes. Combat stress is in part dose and duration related. Killing is entrained but not extinguished by existing rehabilitation efforts. Young men and women with a history of abuse and familial mental illness are at higher risk, but they continue to be enlisted with regularity despite claims to the contrary. We glorify the soldiers’ motives to participate in conflict but do not look critically enough at the cultural and national issues that cause leaders to choose to decimate a significant part of the character and stability of our future generations. This is not just a job you may not live long enough to leave; it is a job that never leaves you.

Phyllis Henderson, MD
Board Certified Psychiatrist
Read more!

Tuesday, August 4, 2009

Psychiatrists, Pain Specialists, and the Physicalist Fallacy: Who Are the "Real" Doctors?

You know the drill, but in case you have repressed it, the antipsychiatry mantra goes something like this: “Real” disease is present only when we can point to a lump, bump, or lesion—or at least, to a specific physiochemical abnormality in association with a specific set of signs and symptoms. Anything else that we call “disease” is simply a label—a “social construct” akin to terms like “primitive” or “fanatic” without any scientific validity. By implication, “real doctors” are those who treat the corresponding “real diseases.” Since, for the major mental disorders, psychiatrists cannot point to causally implicated lumps, bumps, or lesions—or to specific pathophysiological defects—they are not treating “real” diseases; therefore, as the mantra goes, they are not “real doctors”! These arguments compose what I call the “Physicalist Fallacy” of psychiatric diagnosis, which is not to be confused with the concept of “physicalism” per se. The Physicalist Fallacy is a kind of philosophical mongrel with a lineage derived from logical positivism, Cartesian dualism, and a gene or two from “post-modernism.”

Rebuttals to these fallacious arguments have been given at length and I won’t risk inducing stupor and coma by rehashing them here. I won’t even belabor the point that when Eugen Bleuler wrote his classic text in 1911, he referred to “the schizophrenias” (plural); and that abnormal smooth pursuit eye movements (SPEMs) are one of several reasonably well-established biological findings in what is probably a related group of schizophreniform disorders (see "Beyond Reliability: Biomarkers and Validity in Psychiatry" and "How Clinical Neurophysiology May Contribute to the Understanding of a Psychiatric Disease Such as Schizophrenia" for further reading). Rather, to understand why psychiatry is in its present predicament—regarding the public’s jaundiced view of psychiatry and the raging debate over the DSM-V—it is helpful to examine the work of our colleagues in the field of chronic pain treatment. To escape our predicament, we need to examine the philosophers and psychiatrists (such as Karl Jaspers, 1883-1969) who have taken a phenomenological approach to the recognition of “disease”—a point my colleagues Michael A. Schwartz and Nassir Ghaemi have repeatedly stressed. To oversimplify greatly: phenomenology refers to the structure of the patient’s experience—how, for example, self and world are perceived during a bout of psychotic depression.

Based mainly on animal models, there have been major advances in understanding the pathophysiology of chronic neuropathic pain—yet there is a great deal we still do not know. Moreover, diagnosis and treatment of chronic, idiopathic pain (of unknown etiology) remains essentially grounded in the patient’s subjective complaints combined with objective findings in the doctor’s office or bedside examination. This is analogous to the psychiatrist’s initial history-taking and mental status examination. Pain specialists dealing with chronic, idiopathic pain cannot, by definition, point to a specific lump or lesion that explains the patient’s suffering. Yet—with the exception of those thought to be “malingerers”—we do not delegitimize the patient’s complaints. We do not regard individuals with chronic pain as having a “metaphorical” illness. We do not brand doctors who treat these patients as charlatans. On a societal level, we do not find a robust “Anti-Analgesia” movement, bristling with vicious blogs and insulting placards. Why, then, the animus toward psychiatric practice?

The answers are far too complex to cover in this space, but, in my view, relate to at least two factors:

1. Individuals with chronic pain are ordinarily self-identified and voluntarily seek treatment for their condition; in contrast, many individuals with serious psychiatric impairments do not. Indeed, it is the very nature of their illness that they often deny its presence or significance.
2. Legislatures, courts, and common-law tradition have not sought to impose mandatory or involuntary treatment upon those with chronic, idiopathic pain disorders; this is clearly not the case for some individuals with severe psychiatric conditions that represent “an immediate danger to self or others”. (For more on the public’s misunderstanding of the psychiatrist’s role in “commitment” procedures, see "In the US, Psychiatrists Do Not 'Commit" the Mentally Ill").

Arguably, these forensic aspects of psychiatry may call for legislative and societal remedies—but by themselves, do not impugn the legitimacy of psychiatric diagnosis and treatment.

That said, we should strive to be as parsimonious and “objective” in our diagnostic categories as possible. To paraphrase Ockham’s Razor, we must not “multiply entities unnecessarily” in creating our disease categories. We should certainly avoid creating new categories that are not grounded in careful empirical and phenomenological investigations. But whereas our long-term goals should include pinning our DSM categories to specific biochemical and genetic markers, we should reject the positivist “lumps and labs” model of disease. Our focus, rather, must remain on relieving suffering and incapacity in its infinite experiential presentations. In this, we need to learn from our colleagues in the chronic pain field.

Note: I wish to thank Michael A. Schwartz MD and S. N. Ghaemi MD for their helpful comments on this piece; however, I alone am responsible for the views expressed.

Ronald Pies, MD
Editor-in-Chief, Psychiatric Times
Read more!

Thursday, July 30, 2009

The DSM-V Flap

It is troubling to discover demonizing polarization in discussions of DSM-V. It has been bad enough witnessing such primitive splitting in our political life.

While Dr. Frances (“A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences,” Psychiatric Times, June 26, 2009) raises legitimate concerns regarding the "unintended consequences" of major diagnostic reform, he never fully acknowledges the present consequences of DSM-IV. His recommendation that we wait until biological etiologies are more certain is both overidealizing of neuroscience and underestimating of the unintended damage being done with check list diagnoses of DSM-IV. The main function of a diagnosis is to maximize accurate perception and therapeutic efficacy. The false clarity of many DSM-IV categories no longer serves these goals. A nosology of symptoms has neither adequate biological nor psychological coherence in light of the past 40 years of clinical and research knowledge.

As is well known, the DSM emerged from the needs of pharmacologic research that required standardization depending on diagnostic consistency and international consensus on criteria. Unfortunately, the definition of disorders designed for this research took on the status of medical disorders like strep throat. Single transmitter theories predominated. An insidious reductionism resulted both within and outside psychiatric practice. Today, DSM-IV diagnoses are taught to medical students for “biopsychosocial” competence. Students are lead to believe the entities (developed 40 years ago) are naturally occurring disorders, not approximate symptom clusters established for drug trials. Primary care docs (who prescribe the majority of psych meds) rely exclusively on simplistic screening tools and check lists to direct treatment. Insurance companies require documentation of “biologically based” disorders for payment.

An “unintended consequence” of DSM-IV (even with the 5-axis diagnosis) has been a mishmash of pseudo-scientific reasoning. Steven Rose noted at a Novartis symposium that no MD would say a fracture, relieved by codeine, is a codeine deficiency disorder. Yet, our psychiatric nosology often reinforces this reductionism by implying each disorder is a specific “chemical imbalance” with a fixed set of behaviors that should be corrected by the right medication (e.g., if DA blockers reduced auditory hallucinations, then the disease called schizophrenia is a DA excess disorder; if an SSRI modulates some obsessional symptoms, it must be a 5HT deficiency.)

Unlike Dr. Frances, I would not await imagined certainties of neuroscience before reforming DSM. No matter what brain event we observe, the risk of faulty attributions of cause would persist. (Pharmaceutical companies would exploit any system to sell their products—dimensional or categorical.). Moreover, psychiatry has a mixed record when biological models prevailed (see: insulin coma, prefrontal lobotomy, neurotoxic drugs, etc.). Recent biological muddles (predicting resilience with long vs. short 5HT alleles, the ongoing search for a genetic marker for schizophreniform disorders, dexamethasone suppression tests) should make us skeptical about awaiting a neuroscience Rosetta Stone.

Other problems of current diagnostic approaches include:
– undertreatment of psychiatric patients for medical problems
– undertreatment of medical patients for psychological problems
– pejorative use of somatization in addressing pain or psychological coping
- pejorative use of “personality disorder” diagnosis
– replacement of in-depth interview and formal mental status examination with impressionistic assessment derived from a few symptoms
– failure to conceptualize a variant on PTSD in many medical and surgical patients who experienced shocking pain or sudden disability
- failure to address a patient's amalgam of inheritance, attachment, environment, mood, behavior, fantasy, and the unique adaptation of a personality to life events

We will always need to discover our patients in an individualized, dimensional, and interpersonal field to honor human reality; no fMRI, mirror neuron, or serotonin allele can supplant a true dimensional matrix.

The newer models that recognize the interplay of gene and environment provide a better perspective; the understanding that 5HT modulation is helpful in almost all categories of illness—targeting many different CNS regions with distinct 5HT receptors and functions—has moved science away from the one disorder/one medicine hype so popular with pharmaceutical marketeers. Dubovsky and Stahl have long clarified the inadequacy of “chemical imbalance” models and how symptoms actually cluster and evolve within a complex individual context. The categorical model is no longer sufficient to guide much prescribing or psychological treatments.

Although Dr. Frances seems to denounce the DSM-V team as one in an ivory tower, their new dimensional approach responds to decades of clinical observation. The actual mix of mood, relational style, thought process, and functioning should be essential to our diagnostic framework and not relegated to charting a 5-axis discharge diagnosis. I have been in private practice for 30 years and have struggled to make many of my patients “fit” into a DSM-IV category. Axis 2 diagnoses—poorly conceptualized in DSM-IV—trigger insurance denials. It is ironic that insurers have stigmatized axis 2 even though there is reason to believe these complex patients require repeated costly hospitalizations. Biological parity forces overuse of “bipolar,” which in turn promotes prescribing expensive and toxic mood stabilizers—some with serious adverse effects—often with little substantive benefit, which in turn stirs more “aggressive” polypharmacy. Only quite recently have interpersonal treatments attracted mainstream research attention despite the years of Big Pharma promoting Bipolar Disorder and ADHD.

The study of early life stress and adult pathology is helping to close the bio-psychological divide, but has little traction in DSM-IV.

So while I am grateful for the caution Dr. Frances promotes I fear it may hamper the development of DSM-V. Clinicians have been trapped for too long with an antiquated manual into which patients are squeezed; sometimes damaged by the illusion that the diagnosis they've been given exists as a real entity with a simple cure.Better we give more than false clarity; let's hope DSM-V will help us see what is rather than starting with a category within which we must locate our patients.

Sara Hartley, MD
Read more!

Tuesday, July 21, 2009

Dr Rosenblum speaks up regarding APA's response to Dr Frances

Dr Stephen Rosenblum, Life Fellow, APA writes:

"I found the American Psychiatric Association's response ("Setting the Record Straight", Psychiatric Times, July 1,2009) to Dr. Alan Frances's commentary ("A Warning Sign on the Road to DSM-V", Psychiatric Times, June 26, 2009) outlining his concerns about the DSM-V an embarrassing, black mark against the Association. As President of an organization supposedly devoted to scientific objectivity, Dr Alan Schatzberg's (lead author of the response) ad hominem attack and use of unprovable innuendos to discredit Dr. Frances reflects an approach I want nothing to do with.

If Dr. Schatzberg and his coauthors need an example of a professional, objective and scientific response to Dr. Frances they should refer to Dr. William T. Carpenter's commentary "Criticism vs. Fact" (Psychiatric Times, July 7, 2009, or to Dr. Renato D. Alarcon's essay "Inside the DSM-V Process: Issues, Debates, and Reflection." Both authors counter Dr. Frances's arguments without attacking him personally.

I can only assume that as President of the APA, Dr. Schatzberg reperesents the mind set of our organization. If that is so, it is an organization with which I take no pride in my affiliation." Read more!

Thursday, July 16, 2009

Doctor, Are You "Drugging" or Medicating Your Patients? Antipsychiatry and the War of Words

You have read the blogs and seen the placards a dozen times: doctors prescribe too many “drugs” for too many patients. Psychiatrists, in particular, are popular targets of politically-motivated language that seeks to conflate the words “medication” and “drug”—thereby tapping into the public’s understandable fears concerning “drug abuse” and our need to carry out a “War on Drugs”. Misleading radio ads promise “drug-free” treatment of panic disorder (certainly possible, but not always achievable) and the Internet bristles with the phrase, “psychiatric drugging” (my Google search pulled up 9,310 results). And, all too predictably, any physician who argues that psychotropic medication is often an effective and life-saving intervention is hustled off to the perp-line of “drug company shills.”

All this will not surprise students of language, history, and philosophy. Those who control language are well-positioned to control thought and behavior. If government officials can persuade the public that killing innocent civilians is merely “collateral damage”, they have gone a long way toward justifying the carpet-bombing of a village. If the forces of anti-psychiatry—and they are alive and well—can persuade the public that psychiatry is “drugging” people, they have gone a long way toward marginalizing and discrediting the profession. To understand how powerful the words “drug” and “drugging” are, imagine the feckless campaign that would be waged if the perennial protesters in front of the APA’s Annual Meeting carried signs that read, “Psychiatrists: Stop Medicating Your Patients!”

Is this all merely a matter of “semantics” or—in the parlance of post-modernism—“competing narratives”? Is there any scientific reason to distinguish “drugs” from “medications”? And finally, what are our ethical obligations as healers when medication is administered, either voluntarily or involuntarily? I will have more to say on these matters in a more detailed version of this blog, and in a follow-up piece on the considerable good that psychiatric treatment can do.

Yes, one can argue that, in today’s setting of “mis-managed care,” psychotropic medication is sometimes prescribed too readily, when psychotherapy would be the preferred treatment. And, yes: we need more effective medications in psychiatry, used in more judicious ways--particularly in children, adolescents, and those with dementia, for whom our evidence-base is often shaky. We should be wary of attempts to expand both our disease categories and the labeled indications for psychotropic medications.

Finally, let there be no doubt that, as physicians and healers, psychiatrists have an ethical responsibility to see that medications are prescribed and administered in a compassionate and non-coercive way, consistent with the principles of informed consent and respect for personal autonomy.

But to lump all psychotropic medications in with drugs of abuse is to embrace junk science and junk rhetoric. Psychiatrists need to find a gentle but persuasive language of resistance, in the face of this ploy.

Ronald Pies, MD, Editor-in-Chief
Read more!

Tuesday, July 14, 2009

Resignation Letter to DSM-V Workgroup

Dr Jane Costello, PhD, professor in the department of psychiatry and behavioral sciences at Duke University and former DSM-V Workgroup member resigned from the Child and Adolescent Workgroup in March after feeling that the development of the new edition was off-track. Dr Costello shared the letter she sent to Workgroup leader, Danny Pine, MD (NIMH). A copy of the letter she sent follows.

Dear Danny;
As we discussed at the DSM-V meeting last week,
I am resigning from the Child and Adolescent Disorders workgroup. As you know, I
have been thinking about this for some time, but have been reluctant to take
this step because I very much enjoy working with this extraordinary group of
people, and learning so much from them. However, I cannot in good conscience
continue. These are my reasons:

1. I am increasingly uncomfortable with the
whole underlying principle of rewriting the entire psychiatric taxonomy at one
time. I am not aware of any other branch of medicine that does anything like
this. (The ICD revisions make no attempt to rewrite the details of each
diagnosis.) There seems to be no good scientific justification for doing this,
and certainly none for doing it in 2012.

2. When we began this process, we
agreed that changes would only be made if there were empirical evidence to
support them. Sometimes (as with Charlie’s [Charles Zeanah, MD, Tulane
University] work on preschool PTSD) this has been the case. But as time has gone
by, the gap between what we need to know in order to make revisions and what we
do know has grown wider and wider, while the time to fill these gaps is
shrinking rapidly. More and more, changes seem to be made for reasons that have
little basis in new scientific findings or organized clinical or epidemiological

3. Efforts by Pat Cohen [Patricia Cohen, Ph.D., Columbia University]
and myself in 2007 to provide data to fill some of the gaps in the knowledge
base were rejected. One reason given by David [David Kupfer, MD, Univeristy of
Pittsburgh] was that the answers to questions were needed within 6 months, i.e.,
by the end of 2007. Now Prudence’s [Prudence Fisher, Ph.D., Columbia University]
grant has a favorable review and may be funded by the fall of 2009, with data
available perhaps in 2010. As far as I am aware there is not yet a process in
place for feeding to Prudence the questions that the data sets could be used to
answer, so any results are likely to be even more delayed. This, as we have all
agreed, makes no sense.

4. One reason why it took so long to get a data base in
place was that a decision was made that the work had to be done via a grant
application to NIMH, with all the time delays entailed by that process. The
reason given was that the funding allocated by the APA for research for DSM-V
was not enough to support the necessary work. I continue to be shocked that the
APA would even consider revising the DSM without being willing to allocate the
funding necessary to carry out the underlying scientific studies. A drug company
that tried to bring a product to market on the basis of inadequately-funded
research would rightly be censured. This is what the APA is doing, and now that
it is quite clear what is happening I am afraid that I cannot bring myself to be
part of the process any longer.

5. The tipping point for me was the memo from
David and Darrel [Darrel Regier, MD, American Psychiatric Association] on
February 18, 2009, stating “Thus, we have decided that one if not the major
difference between DSM-IV and DSM-V will be the more prominent use of
dimensional measures in DSM-V”, and going on to introduce an Instrument
Assessment Study Group that will advise workgroups on the choice of old scale
measures or the creation of new ones. Setting aside the question of who
“decided”, on what grounds, anyone with any experience of instrument development
knows that what they proposed last month is a huge task, and a very expensive
one. The possibility of doing a psychometrically careful and responsible job
given the time and resources available is remote, while to do anything less is

It has taken me a long time to reach this conclusion,
largely because I greatly value and enjoy working with you and the workgroup,
and respect your commitment to the DSM-V process. I honor your position – that
given DSM-V is going to be written, the best people should do it. You know that,
as always, I am ready, as in the past, to carry out any data analyses that could
be helpful to your decision-making on specific issues. Please give my greetings
to the rest of the workgroup, and feel free to share with them as much of this
as you choose.

Read more!

Wednesday, July 8, 2009

Frances and Spitzer: A Message to DSM-V Workgroup

Drs Spitzer and Frances sent over the following in response to Dr Renato Alarcon's article, "Inside the DSM-V Process: Issues, Debates, and Reflections" (Psychiatric Times, July 2009, p 1).

We have no argument at all with any of the DSM-V work group members, all of whom undoubtedly have the best of intentions and are working hard to do a good job in revising the diagnostic system. Indeed, we are pleased that Workgroup members have often made their own efforts to engage in discussions with their colleagues and are making presentations about their work at meetings.

Instead, our problem is with the conditions imposed on the work group members by the DSM-V leadership, particularly: (1) the confidentiality agreements; (2) the unwillingness to post on the DSM-V Web site the work done so far by the workgroups (i.e., the literature reviews, results of any of the secondary data analyses, and, most importantly, the exact wording of the proposed criteria sets or dimensions; and (3)the rush to prematurely start these field trials in order to meet an artificially imposed publication deadline.

The basic, obvious, and unanswered question is how can field trials begin now before any of the DSM-V options and supportive literature have been posted and time given for a thorough critique from the entire field? Would it not help Dr Alarcon and other work group members to get input from the largest possible number of reviewers before deciding on which suggestions deserve to move forward and which have too many previously unrecognized risky unintended consequences? Would Dr Alarcon and other work group members not prefer to be given sufficient time to make sure that DSM-V is as problem-free as possible?

There is no justification for a fixed publication date in 2012 now that ICD-11 will not appear before 2014. Let's have everything posted and thoroughly reviewed first, and then it will be appropriate to plan field trials. We wrote to the American Psychiatric Association Board of Trustees precisely to help ensure the best possible environment for the efforts of Workgroup members like Dr. Alarcon - an environment unconstrained by confidentiality agreements, artificial time pressures, and lack of external input. We wish him (and all the DSM-V Workgroup members) well in their continued work on DSM-V.

Allen Frances, MD and Rober Spitzer, MD
Read more!

Monday, July 6, 2009

Calling all Psychiatrist-Artists

Psychiatric Times is collecting a library of images to use to illustrate our articles in print or online.

If you would like your artwork to be considered for inclusion in our image library, please e-mail us a high-resolution file (TIFF, JPG, EPS, PDF - no more than 10mb) along with the title of the work and the medium used. Images will be reviewed by the editors and accepted art will be used online or in print to illustrate articles in Psychiatric Times. Your byline and contact information will be included. Psychiatric Times will have nonexclusive rights to reproduce the accepted image either in print or online. Artists will retain the right to sell or use the image as they see fit. Read more!

Thursday, July 2, 2009

APA Responds to Dr Frances

On Wednesday, the APA submitted a formal response to Dr. Frances' commentary, "A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences Here's an excerpt:

"The process for developing DSM-V has been the most open and inclusive ever. The process began with a planning session that led to 13 NIH-supported international research conferences and a series of monographs. These conferences included more than 400 scientists, clinicians and others in the field. The DSM-V Task Force and Work Groups include more than 150 experts in various specialties and sub-specialties from 16 countries, including both scientists and clinicians. Over 200 advisors have thus far been asked to share expertise with DSM Work Groups. The DSM-V Task Force established a Web site, www.dsm5.org, to accept comments and provide work group updates. Unfortunately, to bolster his unjustified ad hominem attacks, Dr. Frances used the readily available DSM-V updates and misrepresented them as final decisions, rather than as statements of work in progress."

Read the rest of the article and send us your comments.
Read more!

Tuesday, June 30, 2009

Dr. Warren’s “DSM-Minus-IV”: Lessons for DSM-V?

The compelling article, "A Warning Sign on the Road to DSM-V," by Dr. Allen J. Frances,
inspired me to pull a brittle, yellowed old tome off my bookshelf. Warren’s Household Physician, based on the work of Massachusetts physician, Dr. Ira Warren, was first published in 1859 as a “brief description, in plain language, of all the diseases of men, women and children . . .”. The chapter titled, “Diseases of the Brain and Nerves”—what I call, the DSM-Minus-IV—is a gem of holistic thinking. Dr. Warren essentially unifies afflictions often called “neurological disorders” with those nowadays considered the domain of psychiatry. Thus, Dr. Warren addresses various types of brain inflammation, chorea, and neuralgia in the same chapter that addresses “derangement of mind” or “insanity.” Indeed, the good doctor seems uncomfortable with Cartesian dualism, noting that:

“Some have supposed insanity to be a mental disorder merely, having nothing to do with the body. They might as well suppose the delirium of fever to be a disease of the mind only.”

Under the general rubric of “insanity”, Warren includes only 5 main types: melancholy, monomania (“insanity on one subject”); mania, dementia, and idiocy. (This last category - in which “the brain is not large enough to be the organ of intelligence” - is similar to what neurologists would call anencephaly). Closing out his “DSM,” Warren discusses hypochondria—apparently not a cause of insanity, but nevertheless a brain disease characterized by “. . . constant fear, anxiety, and gloom.”

Now Dr. Warren’s classification is far from perfect. For example, Warren did not clearly distinguish bipolar disorder (or manic-depressive illness) from schizophrenia, as Emile Kraepelin would do about a quarter century later. (Then again—some recent genetic studies have challenged this dichotomy; see, e.g., Craddock et al, Schizophr Bull. 2009 May;35(3):482-90. Epub 2009 Mar 27.) And, let us be clear: we need more than 6 major disorders to capture the range of psychopathology we have delineated since 1859. But Dr. Warren’s pared-down classification—has Occam’s Razor ever shaved so close?—seems at one with the spirit of Dr. Frances’s critique.

Indeed, I suspect that Dr. Warren would agree that we must avoid expanding the DSM beyond what is absolutely necessary—and scientifically supportable. I, too, share with Dr. Frances the fear that extending the DSM’s reach in the absence of convincing data will further undermine psychiatry’s already battered credibility. For example, I have argued against reifying such proposed “disorders” as “Pathological Bigotry” and “Internet Addiction.”

The issue of “sub-syndromal” or “pre-clinical” conditions poses further conundrums. In psychiatry, as in all of medicine, there is always a tension between the sensitivity and specificity of our disease criteria—in essence, between how large a descriptive “net” we cast and how fine we weave its mesh. Ideally, both current and proposed disease categories should be built on a firm base of epidemiological, biological, observational, and phenomenological data . Absent this foundation, Dr. Frances rightly cautions us against building castles in the air.

And yet, we should view the task of the DSM-V directors with some empathy. “Objective science”—if there is such a thing—can take us only so far. Ultimately, the disease categories we create reflect complex existential decisions, not mathematical equations. We should be guided not by a need to increase or decrease the number of DSM diagnoses nor merely by a desire to safeguard psychiatry’s reputation. Our pole star must remain the healer’s ancient charge: to reduce human misery and enhance the blessings of health.

Ronald Pies, MD

Read more!

Monday, June 29, 2009

DSM-V Controversies: A Commentary from Dr Allen Frances

Chair of DSM-IV Task Force, Dr Allen Frances, has written a commentary, "A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences." Here's an excerpt:

"We should begin with full disclosure. As head of the DSM-IV Task Force, I established strict guidelines to ensure that changes from DSM-III-R to DSM-IV would be few and well supported by empirical data. Please keep this history in mind as you read my numerous criticisms of the current DSM-V process. It is reasonable for you to wonder whether I have an inherently conservative bias or am protecting my own DSM-IV baby. I feel sure that I am identifying grave problems in the DSM-V goals, methods, and products, but it is for the reader to judge my objectivity."

To read the rest of the article, click here. PT will be featuring a question and answer from Dr Frances all week on the blog.

Read more!

Friday, June 26, 2009

Parents Who Kill

The article by Drs Hatters-Friedman and Resnick (“Parents Who Kill: Why They Do It,” Psychiatric Times, May) was a clinically useful overview of filicide—particularly with respect to the motives that underlie this disturbing and tragic pattern of intrafamilial violence.

Lower IQ is associated with many neuropsychiatric disorders. Studies suggest that this may also be the case with filicide (Farooque R, Ernst FA. J Natl Med Assoc. 2003.) Therefore, psychological/neuropsychological testing, with rule-outs of borderline intellectual functioning and mild generalized cognitive disability (mild mental retardation), is advisable in cases where, following an act of filicide, the parent’s history and/or mental status suggest the possibility of lowered intellectual capacity. Such a finding is likely to have significant treatment planning and forensic implications.

Jerrold Pollak, PhD
Program in Medical and Forensic Neuropsychology
Seacoast Mental Health Center, Portsmouth, New Hampshire

Read more!

Friday, June 19, 2009

More on off-label prescribing

I was fortunate enough to get great training (SUNY-Upstate for MD and Oregon for residency/child fellowship). After graduating I promised myself I would be true to my psychodynamic roots (Hal Boeverman RIP), do thorough evaluations and provide the finest psychiatric care possible. After leaving Oregon I happened to travel through Montana on the way to visit my family back in NY State. I was smitten.

I am always amazed at the differences between academic and community psychiatrists.

Fortunately a job was available in Billings, and here I have been ever since. I felt like quite the bright young thing arriving in the hinterlands and remember being appalled when the first thing my nurse asked me for was a presigned book of prescriptions, since she did most of the refills. I was horrified at the thought! The signature is sacred! I soon figured out that my nurse knew more about child psychiatry than I ever would, and the scrips were signed.

Now we do everything via computer, and I just sign the controlled substances. I also found out that I had inherited a practice of hundreds upon hundreds of children and adolescents. Our four-man clinic runs the only child unit for hundreds of miles in all directions. It is not uncommon for people to drive ten hours for an appointment. I quickly abandoned my idealistic hope of providing exquisite care for the few, and began my life’s work of providing pretty decent care for many. And obviously, I have become fairly comfortable with the 90-min evaluations and the 25-min med check.

But when I see an article like Dr. Edersheims’s excellent piece on off label prescribing of atypicals, I have this horrible mixture of guilt and despair. Edersheim nicely makes an argument for how to handle the vagaries of off-label prescribing, but if I tried to practice even a fifth of her ideals regarding extra info, collecting articles, more monitoring, increased consultation, I would never make it past my 9:00 appointment.

The reality is I have a 10 year old from Lewistown hallucinating in my office and the next patient is a 14-year-old from Billings who has broken up with a boyfriend and wants to die. The other reality is that I am about it. Therapists are rare in rural Montana. Pediatricians and family practitioners don’t want to go near this stuff. So of course I am going to go off-label.

I am a general child psychiatrist; everything (practically) is off-label. And it seems to me we have gotten so defensive and fixated about medication side effects (which can be horrible!) that we as a profession go into denial about what happens if we don’t treat these conditions. We have just a relative few weapons for a lot of chronic, dangerous illnesses. They need to be prescribed as intelligently as possible, but we also need to understand that those of us in the field need to treat a lot people quickly and efficiently and to not underestimate the morbidity and mortality of ignoring the plight of folks who need “off-label” treatment.

Jim Peak MD
Billings, MT

Read more!

Monday, June 8, 2009

A moment defined

If only we doctors could memorialize those defining moments in our careers as beautifully as did Richard Berlin in "Teaching Rounds."
In my year of Neurology many moons ago I was called to the ward because a patient had died. On the bed lay this little boy. His skin was white as Carrara marble but blotched with purple marks from the hemorrhages of leukemia. All alone, at 3 in the morning with this precious life forever stilled, I stood in silent prayer, keeping him company, marveling at the beauty, grieving for the future he would never know.

Thank you Richard Berlin. Thank you Psychiatric Times.

Barbara Young

Read more!

Monday, June 1, 2009

Atypicals: Off-label

The off-label use of psychotropic medications was nicely reviewed by Judith G. Edersheim, MD, in the April 2009 issue of Psychiatric Times. Recently, there has been increasing interest in—some would say “hype” about—the use of atypical antipsychotics (AAPs) to treat a variety of nonpsychotic conditions or symptoms.

Thus, there is intense interest in the use of AAPs for refractory depressive states, bipolar disorder, and anxiety disorders—none of which necessarily involves the presence of psychosis! Is this a justifiable “off-label” practice? Are these drugs being hyped by “Big Pharma” to expand its market base, or is there a sound, evidence-based foundation for the use of AAPs in nonpsychotic conditions? (Both propositions could be true, of course!) Is it even correct to consider these agents as “antipsychotic” medications, or would it be more accurate to consider them “broad-spectrum,” cognition-affect modulators? Does reconsideration of the AAPs in this light remove or mitigate the medico-legal problems associated with their off-label use (eg, the risk of tardive dyskinesia, neuroleptic malignant syndrome, and metabolic syndrome)?

—Ronald Pies, MD (Editor in Chief)

PS: For a good background article on the use of AAPs in anxiety disorders, you might take a look at the excellent review by Gao and colleagues in the Journal of Clinical Psychiatry.

Read more!

Tuesday, May 12, 2009

The "McDonaldization" of Psychiatry: Psychiatric Knowledge is Not the Equivalent of "Fast Food"

I was only in callow adolescence in April of 1964, but I remember those times quite clearly. The country had just come through the assassination of JFK, and Vietnam was already looming on the national horizon. Simon and Garfunkel had just written their anthem of angst, “The Sounds of Silence”, and the nation would soon be roiled by student protests known as the Berkeley Free Speech Movement. More distantly, in the din of these events, a young psychiatrist named Melvin Gray published an article in the Archives of General Psychiatry, entitled “Principles of the Comprehensive Examination.”1 Today, as our field confronts so many challenges—epitomized on this blog as “The Couch in Crisis”—Dr Gray’s article should be read or re-read by everyone committed to psychiatry’s survival as a medical specialty.

According to Wikipedia, “McDonaldization…is a term used by sociologist George Ritzer in his book The McDonaldization of Society (1995). He describes it as the process by which a society takes on the characteristics of a fast-food restaurant.” The 4 primary features of McDonaldization, according to Ritzer, are efficiency, calculabilty, predictability, and control. Mind you, I have nothing against the occasional fast-food stop, and I will even confess to a weakness for cheeseburgers. But the McDonaldization of psychiatry is hardly the model of diagnosis and treatment we should embrace. And yet, many would argue, that is what we are now facing, as psychiatric diagnosis is reduced to endorsing and coding check-lists of manifest signs and symptoms; the 50-minute hour is reduced to the 15-minute “med check”; and psychotherapeutic acumen is reduced to a few perfunctory courses during residency. To be sure, there are many commendable exceptions to these trends, and many eloquent voices raised in discontent.2-5 Yet as we move toward the new diagnostic framework known as DSM-V, our field is arguably in the fight of its life.

It should be noted that “reductionism” in psychiatry is not confined to those who strenuously advocate DSM-style categorical diagnoses or purely biological approaches to understanding psychopathology. As one of our Psychiatric Times Board members, Dr Glen Gabbard has observed, “Both [psychoanalysts] and their patients secretly are drawn to simple formulations that eschew complexity.”3 Reductionism, in short, is an equal-opportunity state of mind.

Dr Mel Gray’s wise article—prescient in so many respects, given the problems facing present-day psychiatry—is just what the doctor ordered, even if it bears a prescription date of April, 1964. Though it appears in the Archives of General Psychiatry, it is aimed at “…the young physician…in whatever field of medicine” he or she may practice. For those of us who have become accustomed to doing a half-hour—or perhaps an hour—of initial diagnostic assessment, Dr Gray has this to say:

“The comprehensive examination requires a minimum of four to six hours. Since three to five days of examinations, observations, and tests are usual in the outstanding medical clinics in the United States, the time suggested here is relatively short.”1

Ah, as the song goes, “Those were the days, my friend!” Dr Gray’s comprehensive assessment includes not only the traditional “Chief complaint” and history of the present illness, but also a “hereditary” and “ontogenetic” biography—the former dealing with familial psychiatric illnesses, and the latter, with “…changes both normal and pathological of the individual from the time of conception to the present.” Dr Gray pays due attention to determining “the precipitating cause or causes” of the patient’s complaint, but he is skeptical regarding facile causal narratives. He writes,

“The possibility of inaccuracies increases the more one depends upon the patient’s observations and explanations. . . Although speculation is acceptable, it should not be given unwarranted value. The further one gets from the present, the more speculative becomes the explanation and the greater the danger of espousing a false causality.”1

This wisdom flies in the face of modern recourse to single, “contextual” precipitants for a patient’s depressed mood, or—for that matter—to facile explanations based on “chemical imbalances” or other biological causes. Rather, Dr Gray insists that we must assess the “total person”, by which he means

“…the cultural, sociological, biographic, biological, psychological, and behavioral levels of organization…”1

At a time when psychoanalytic concerns about “boundary violations” were discouraging psychiatrists from performing physical examinations,6 Dr Gray prominently advocated physical examination as a fundamental element of the comprehensive medical-psychiatric assessment.

Dr Gray’s synoptic description of what psychiatrists and all physicians must know reminds me of the wonderful short story by the Russian-Jewish writer, Isaac Babel (1894-1940)—“You Must Know Everything.”7 This is a tall order, of course, but it reflects the view that psychiatry will not survive, much less thrive, as a profession, if it narrows its focus and lowers its sights.8,9 Psychiatric knowledge is not the equivalent of “fast food”; rather, it is a feast that must be carefully prepared, lovingly consumed, and slowly digested.

1. Gray M. Principles of the comprehensive examination. Arch Gen Psychiatry. 1964;10:370-381.
2. Ghaemi SN. Existence and pluralism: the rediscovery of Karl Jaspers. Psychopathology. 2007;40:75-82.
3. Gabbard GO. “Bound in a nutshell”: thoughts on complexity, reductionism, and “infinite space.” Int J Psychoanal. 2007;88(Pt 3):559-574.
4. Geppert CMA. Why psychiatrists should read the humanities. Psychiatric Times. 24;2:February 1, 2008.
5. Genova P. The Thaw. Hillsdale NJ, The Analytic Press, 2002.
6. Kick SD. Medical training in psychiatry residency: a proposed curriculum. Gen Hosp Psychiatry. 1997;19:259-266.
7. Babel I. You Must Know Everything, Stories 1915-1937. Translated from Russian by Max Hayward. Edited, and with notes by Nathalie Babel, Farrar Straus and Giroux, New York, 1966.
8. Pies R. Why psychiatry and neurology cannot simply merge. J Neuropsychiatry Clin Neurosci. 2005; 17:304-309.
9. Pies R, Geppert CMA. Beyond clinical neuroscience: encephiatrics. (letter) Academic Medicine. (in press).

Acknowledgment: The author wishes to thank Dr Melvin Gray for his article, and for his book, Neuroses: A Comprehensive and Critical View, 1978.

Ronald Pies, MD
Dr Pies is professor of psychiatry and lecturer on bioethics and humanities at SUNY Upstate Medical University in Syracuse and clinical professor of psychiatry at Tufts in Boston.
Read more!

Wednesday, April 1, 2009

I used to be a doctor

I used to be a doctor. Next I was a provider. Now, I’m a non-covered entity. I liked being a doctor…I still do. I never liked being a provider. But being a non-covered entity is a secret victory. I’ll explain.

As a psychoanalyst and psychiatrist, my work depends entirely on confidentiality and respect for people as individuals. Treatment works only when my patients and I are able to explore very personal feelings and thoughts. If my patients are not confident that what they tell me will stay private, they will withhold their thoughts or abort the treatment. In the mid-1980s, when I began practice, what patients told doctors was kept confidential, protected by a compact dating back more than 2000 years, to Hippocrates. Along came private insurers, Medicare, and HMOs—third parties with a financial stake in medical events. Since they were paying out money, they wanted to know what they were paying for, and often began to demand private information before paying. What was personal suddenly became corporate.

To increase profits, insurance companies instituted “managed care” in psychiatry and transferred to shareholders a great deal of the resources that had formerly been spent for health care. Managed care employs many techniques to discourage the use of mental health services. One approach is to have reviewers decide whether patients’ problems meet criteria for “medical necessity” before approving payment for “procedures,” such as psychotherapy. To do this they often demand very personal information, compromising confidentiality. This demand for information, because it threatens confidentiality, can lower quality of care just by existing. Who can talk freely when unseen reviewers are eavesdropping? And, unfortunately, too many therapists are willing to go along with this system.

These same insurance companies made me a Provider. I believe they use the word “provider” as a way to address doctors, nurses, therapists of every variety, even syringe suppliers, with the same form letter. Because a “provider” need not be a doctor, the term also includes the numerous “physician-extenders” who do things that doctors used to do. Many Americans have insurance that obligates them to choose a doctor from a company list or “provider panel.” Even though I don’t participate on insurance company “provider panels” (they rarely allow for confidential, insight-oriented psychotherapy), I have received many a “Dear Provider” letter—impersonal, bureaucratic and, typically, unsigned.

Then came the Health Insurance Portability and Accountability Act (HIPAA), which made me an Entity. HIPAA was intended to help workers maintain their insurance when they changed jobs. It also directed the executive branch to develop regulations to protect medical privacy. While the rules provide new protection for psychotherapy notes, they also allow large companies (including pharmacies) to use personal health information for all sorts of nonmedical (commercial) purposes—without patients’ knowledge or consent. (Perhaps you have received a phone call from a company attempting to sell you products for an illness you thought was confidential?) In addition, the rules require hospitals and most doctors to carry out a lot of bureaucratic paperwork to make a display of privacy protection. You’ve probably signed forms at your doctor’s office to satisfy the rule that the office show you its privacy policies.

If I were to send patient information electronically—such as sending a bill to an insurer online—I would become a Covered Entity and would be forced to have my patients sign the useless forms. But, concerned about these electronic transmissions as an additional risk to confidentiality, I choose not to use them. This makes me a Non-Covered Entity. I’d prefer to be a doctor, but as an Entity, I’d much rather be Non-Covered than Covered.

Not everyone feels as I do. My internist now types on a notebook computer as we talk. Although electronic records are lost, stolen, and sold every day, he does not believe that the electronic record jeopardizes my privacy. If my records were accidentally or maliciously posted on the Internet, would they even be accurate? The problems listed on my billing slip are not necessarily those I consider important. They seem more oriented to justify to a potential third-party reviewer the substantial amount of time my doctor spends with me than an accurate description of my concerns. Would I tell him of problems about which I felt deeply embarrassed?
Now health care reform is in the wind again, and with it many questions. Will insurance companies still be allowed to skim 20% from each health care dollar? Will doctors still be reimbursed huge sums for procedures but pennies for talking with and understanding patients and their families? Can medicine be personal and private? Will people be taken care of by a doctor, a provider, or an entity?

My practice remains personal and private. Most of my patients address me as “Doctor,” but some call me Larry. I’m not particular about this: more important is that the patient be comfortable. If the patient has a strong preference about what to call me, we have the chance to learn from it. The patient’s feelings about addressing me may shed light on his or her feelings in other relationships.

Recently, the federal government has required all doctors (including this Provider/Non-Covered Entity) to have a National Provider Identification (NPI) number. It is 10 digits long, so it’s not easy to address me by it. But even if you are the bureaucrat who created NPIs, your secret will be secure with me.

Lawrence D. Blum, MD
Dr Blum is a psychoanalyst and psychiatrist in private practice in Philadelphia and in Cherry Hill, NJ.
Read more!