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!