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

1 comment:

  1. Thank you. It is important to discuss the realities of the DSM system as it is reified. Younger practitioners do not know the historical and political compromises that led to the DSM. Patients often complain about being "pigeonholed" and "over medicated". The cognitive framework of reductionism that supports this may help researchers, but not always real live patients.