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!

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!

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!

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
Editor-in-Chief

Read more!

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!

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!

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!

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!

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!

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.

References:
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!