Psychosis Risk Proves To Be Indefensible
This lead balloon should be dropped now.
Psychology Today: DSM5 in Distress
by Allen J. Frances, M.D.
January 4, 2012
… Bottom Line: DSM 5 is filled with reckless proposals, but psychosis risk is by far the worst. It was the reason I felt compelled to begin criticizing DSM 5 and should have been dropped years ago. The best interest of APA and DSM 5 would be served not by keeping it ‘up in the air’, but instead by immediately dropping it like the lead balloon it is.
‘Attenuated Psychosis’ Diagnosis Still Up in Air for DSM-5
Psychiatric News
by Mark Moran
November 18, 2011
… In an interview with Psychiatric News, work group member Rajiv Tandon, M.D., said that regarding the criteria for APS, the work group members were not unanimous in recommending inclusion, but felt that the category deserved to be tested in field trials. "The basic idea behind the concept is that by the time someone is diagnosed with schizophrenia, there has been considerable decline in social function and there may have been significant damage to the brain," Tandon said. "The field recognizes that we have to try to intervene earlier, if we can identify those at high risk and if we have safe and effective treatments that can decrease that risk. And we have a model from other branches of medicine for risk syndromes, such as hypercholesterolemia, that are aggressively treated." He said the subject has been the source of controversy from opposite directions. "On the one hand are those who say there is going to be overdiagnosis of kids who might never go on to develop psychosis but who will unnecessarily be treated with antipsychotics," Tandon remarked. "And on the other hand are those, especially in academic research, who say, ‘How can you not include this category? This is a frontier of psychiatry. This is the future.’ " …
This is a no brainer- kids count more than researchers. DSM 5 has to be a workaday manual that is proven safe and scientifically sound as a guide to current clinical practice. It is not meant to be a risky cutting edge research instrument to be fully tested only after it is published.
"The basic idea behind the concept is that by the time someone is diagnosed with schizophrenia, there has been considerable decline in social function and there may have been significant damage to the brain," Tandon said. "The field recognizes that we have to try to intervene earlier, if we can identify those at high risk and if we have safe and effective treatments that can decrease that risk. And we have a model from other branches of medicine for risk syndromes, such as hypercholesterolemia, that are aggressively treated."
speculation x speculation = speculation2:
And as long as I’m on the topic of "may…" and future-think in general, even the basic argument of potential over-medication of kids versus "a frontier of psychiatry" involves speculation on what might happen – speculation about the impact of adding a speculative category. That kind of thinking has no place in a classification of mental disorders. That future-think is something we human beings do well is without question. We have the mental capacity to create a matrix of hypothetical possibilities in our own minds that allows us to plan for the future, choose among courses of action, and speculate. But a classificatory system is not the place to exercise that part of the human mind – a part of the mind that is dysfunctional in the very diagnosis we’re talking around – Schizophrenia [where accurate speculation about the future is often very disturbed].
"And on the other hand are those, especially in academic research, who say, ‘How can you not include this category? This is a frontier of psychiatry.‘" If a group of academic researchers think that Attenuated Psychosis Syndrome [Psychosis Risk Syndrome] is the frontier of psychiatry, I propose they get a grant, explore their frontier, and get back to us with their findings when they have something rock solid. If they think active psychosis damages brains, we’d be pleased to see that evidence as well – rock solid. "This is the future" just won’t do. "This is [by definition] the present".
In the clinic where I work, I see a woman who would’ve definitely fit. She’s heard a voice [she’d named it "Sandy"] since adolescence. The voice periodically chided her for being too short with people, or angry. It said she shouldn’t get so frustrated, that she wasn’t a good mom. I asked lots of questions about the voice. She was adamant it was a voice, not her thoughts. She said she was easily frustrated, impatient, jumpy. Even though she was a smart enough person, she’d quit school as soon as she could – "I hated it." She’d been treated before with antidepressants, antipsychotics, antianxiety drugs and "counseling" ["maybe a multiple"] – all to no avail. She neither had the feel of a psychotic nor a dissociative person. Then she mentioned that one of her kids had ADHD, and I got to asking her ADD questions. To my surprise, she answered every one of them in a positive way, though she had no hyperactivity herself and I hadn’t thought of attentional problems. I tried Adderall 15mg twice a day. A total and immediate cure [don’t get many of those]. That was over a year ago. I saw her this week for a refill and asked about "Sandy." She said, "Oh, I forgot about that. No, that stuff’s all gone." She’s from a pretty primitive Appalachian world, and I would speculate that "Sandy" was some kind of internal mental adaptation to her darting ADD mind. If you met her, you would not question her sanity or mental health.
Mickey, this was a terrific post. I shared it on Twitter and FB. But you hoist yourself with your own petard at the end. You cured someone’s ADD? Allow me a paraphrase: “Get one of those neuroimagers and do brain scans on people until one of them has symptoms of ADD and show us the scans with incontrovertible evidence of a brain lesion.”
You made someone’s phenomenology go away. What did you cure?
I’ve followed your blog for a few months and it has developed into one of my “must-read”s
Here’s a little something that might be relevant to your “Get one of those neuroimagers and do serial brain scans on people until one of them has a schizophrenic break and show us the scans with incontrovertible evidence of brain damage.”:
http://www.ncbi.nlm.nih.gov/pubmed/17851542
Now “may” is a lot smaller word than “incontrovertible” but I found the article I link to and the greater body of reasearch it represents as close to “incontrovertible” as any part of psychiatry (seeing as correlations still rule the day).
Excellent point! A symptomatic cure at best. But after all, it was hallucinations. It’s her word though. She’s kind of a funny lady, and she said, “I’m cured. You cured me!” in a teasing way on her first return…
I appreciate your perspectives about proposed disorders and diagnoses. When a child or adolscent presents with distressing perceptions/thoughts, but not impaired reality testing, what is the standard of practice? Is therapy counseled? If so, what kind? Are there school-based services and supports that are helpful? This may be WAY out in left field, but is there any relationship between tinnitus and auditory hallucinations/hearing voices as external and separate from thoughts?
On a related, but somewhat tangential, note, there is an excellent medical reference blog called The NNT (number need to treat, signifying risk/benefit). The bloggers are emergency physicians who comb the metaanalyses for valid and reliable interventions. Treatments and algorhythms are noted by specialty. Not unsurprisingly, psychiatry is absent. I queried them about that and received a response inviting expert participation. I wonder if you and other psychiatrists who are so incolined would take a look at the site and contribute. I believe contributing that there is a total absence of evidence is valuable and am hoping that you do, too.
I’d suggest to Tandon that the model for hypercholesterolemia may not be the greatest example; yes, it’s been treated aggressively because the statins can often bring down the cholesterol counts. But does that mean they’re preventing heart disease? I’d suggest the evidence is still out on that. And do we really have much knowledge about damage from long term statin use??? My mother, with a family history of cholesterol, died at age 79 following a stroke and then a subsequent fall…the stroke was not the cause of death. The first cause was the hematoma from the fall. The second? liver cancer. We had no idea. No one knew. And this is a lady who never took a drink in her life. So (with little scientific basis) both my sister and I immediately decided to stop taking the statins. Confronted with dying of a heart attack or liver cancer, we opted for the heart attack, if in fact, it may be related. So, Dr. Tandon, imho, bad example.
Thanks Peggi
I skipped the statins but I suspect a lot of pharma-babble in behind their widespread use too…
Hi Mickey, I only recently came across your blog when you reprinted something from my blog about the Hickie/McGorry controversy here in Australia — you’re doing a fantastic job!
I work as an emergency psychiatrist & on some days it seems 90 percent of my patients in crisis have “attenuated psychosis” but the vast majority of them don’t have schizophrenia in any meaningful sense. Yet most of those who have had those symptoms have at some stage earned the SCZ diagnosis despite there being little evidence they have met even the (very loose) DSM-IV criteria. Some of them have even been forcibly treated with depot antipsychotics for long periods in the community, not surprisingly being labelled “treatment resistant” when the voices don’t go away.
You’ve written recently about the fuzzy borders between more and less “biological” mental health problems, and this attenuated psychosis category is a clear example where medicalisation encroaches further on what used to be called problems of living (or variants of normal). If you can’t deal with the fuzziness, just include everything in your definition. We see the same in the way that there is a presumption that the syndromes of bipolar I & II are both “bipolar” in a deeper sense, rather than just sharing certain phenomenological characteristics.
The problem goes quite deep because psychiatry (like medicine) deals with illness in individuals, submitting itself to a kind of methodological individualism — so that when problems are caused by environmental or social factors there are still attempts to reduce them to individually-centred pathology. Psychiatry is dominated by the idea that the individual is both historically and analytically prior to society and the world in which we live. This kind of thinking leads naturally to assuming that unusual phenomena and problems must all be treated at the same level.
Most of my patients who hear voices actually benefit more from addressing their social and interpersonal crises rather than medicating them (except perhaps briefly to relieve immediate distress). The danger of this diagnosis is that we find ever wider groups of people in whom we ignore those simple, practical “treatment” measures. Not to mention forgetting to agitate for social change to resolve problems that lead people to “lose their minds” in various ways.
Huge article in my paper about a local “legal giant” who has “vanished from the legal scene” after accusations of taking clients’ money without performing services and there are numerous bar complaints against him. He has filed for bankruptcy his house has been foreclosed. His defense attorney claims he is suffering with “devastating mental and physical health disorders”. The attorney asked for more time, claiming his client is suffering from depression that has impaired him so significantly he is unable to assist in his own defense. So, Mickey, is this MDD? Is this an “illness”? or is it likely he is genuinely depressed because his house of cards has collapsed? He may not be sorry for what he has done but he may be plenty sorry for getting caught. So, depressed? I would imagine he is. But is this an illness? Not in my book.
Hi Dr_Tad,
I discovered your blog back when I first got interested in McGorry [hubris…] and have visited periodically since then. The fuzziness is what makes psychiatry with individual cases so interesting. I like n=1 psychiatry myself. Sounds like you do too. Welcome. Thanks for visiting…
The speculative argument that the brain is injured without “proper treatment” is used regularly by psychiatrists….
“Prevention” of “brain deterioration” is psychiatry’s mantra…
And it scares the hell outta parents and friends who are not sure what to do; and it persuades people to get on drugs and stay on drugs.
And it “ain’t right” (to use the slang you referred to).
Enough.
Really psychiatry… Enough.
Duane