{"id":15941,"date":"2011-11-13T18:00:18","date_gmt":"2011-11-13T22:00:18","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=15941"},"modified":"2011-11-13T18:50:22","modified_gmt":"2011-11-13T22:50:22","slug":"starting-over","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/11\/13\/starting-over\/","title":{"rendered":"starting over&#8230;"},"content":{"rendered":"<div align=\"justify\">No, this isn&#8217;t another post about the Psychosis Risk Syndrome. I&#8217;ve been clear about my thoughts already. I oppose adding it to the DSM-5. This post is intended to be a post about psychiatric diagnosis in general:        <\/div>\n<blockquote>\n<div align=\"center\"><strong><font color=\"#200020\">Should Attenuated Psychosis Syndrome Be a DSM-5 Diagnosis? <\/font><\/strong><br \/>                <sup>by William T. Carpenter, M.D. and Jim van Os, Ph.D.<\/sup> <br \/>                <strong><font color=\"#004400\">American Journal of Psychiatry<\/font><\/strong> 2011 168:460-463.<\/div>\n<ul>\n<div align=\"justify\"><sup>The  best hope for secondary prevention of the often devastating course of  psychotic disorders resides in early detection and intervention when  individuals first develop symptoms. There is sufficient evidence for  attenuated psychosis syndrome as a clinical syndrome with predictive  validity to establish this diagnostic class. There is much that  clinicians can and should do for care-seeking individuals with distress  and dysfunction who manifest early psychotic-like psychopathology. A new  DSM-5 diagnosis can focus attention on this syndrome and stimulate the  creative acquisition of new knowledge that may be life altering for  afflicted persons. There is little reason to rely on less specific  diagnostic categories, such as anxiety and depression, if we can  reliably give patients and their families a more informative picture of  their situation.<\/sup><\/div>\n<div align=\"right\"><sup>&mdash;William T. Carpenter<\/sup><\/div>\n<\/ul>\n<ul>\n<div align=\"justify\"><sup>The  best hope for early intervention in psychotic disorders resides in  public health measures for the population as a whole rather than in  attempts to diagnose risk in individuals for what will be a low  incidence of future psychosis. Making services more accessible,  providing general diagnostic training to primary care workers, and  creating community awareness will make the filters on the pathway to  mental health treatment more permeable for people with early psychotic  symptoms in need of care. Individual treatment should be initiated early  but when it is indicated, as when criteria are first met for psychotic  disorder not otherwise specified. Creating a diagnostic class that does  not unambiguously define a specific group, treatment, or outcome does  not add value for patients and their families.<\/sup><\/div>\n<div align=\"right\"><sup>&mdash;Jim van Os<\/sup><\/div>\n<\/ul>\n<div align=\"justify\"><sup>The DSM-5 Psychosis Work Group, of which  we are both members, is considering attenuated psychosis syndrome as a  new diagnostic category.  The proposed category reflects the clinical observation that many  adolescents and young adults who eventually develop psychotic disorders  such as schizophrenia first manifest less severe but still troubling  psychotic symptoms in a several-year prodrome before the onset of more  severe illness. Although not all individuals with these attenuated  symptoms will develop a lifelong psychotic illness, the presence of such  symptoms appears to confer a higher risk. An axiom of most medical  practice is that early detection and treatment constitute an essential  strategy to prevent more serious consequences of illness. However, there  is as yet no consensus that this new diagnosis will be helpful in that  regard. In this brief commentary we note some of the more controversial  points&#8230;<\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">While these two members of the DSM-5 Work Group have differing opinions about including this diagnostic entity, they both use the <strong><font color=\"#200020\">implications<\/font><\/strong> of the diagnosis for the future and the <strong><font color=\"#200020\">impact<\/font><\/strong> of making the diagnosis on the patient or family to reach their respective positions [&quot;<em>There is little reason to rely on less specific  diagnostic categories,  such as anxiety and depression, if we can  reliably give patients and  their families a more informative picture of  their situation<\/em>&quot;][&quot;<em>Creating a diagnostic class that does  not unambiguously define a  specific group, treatment, or outcome does  not add value for patients  and their families<\/em>&quot;].        <\/div>\n<blockquote>\n<div align=\"center\"><strong><font color=\"#200020\">Field Testing Attenuated Psychosis Syndrome Criteria <\/font><\/strong><br \/>            <sup>by Judith Rietdijk, M.Sc., Don Linszen, M.D., Ph.D., Mark van der Gaag, Ph.D.<\/sup><br \/>           <strong><font color=\"#004400\">American Journal of Psychiatry<\/font><\/strong> 2011 168:1221-1221.<\/div>\n<p align=\"justify\"><sup>To the Editor:  Attenuated psychotic symptoms that manifest before the first psychotic  episode of schizophrenia are an important and challenging subject in the  field of psychosis. In a commentary in the May 2011 edition of the <em>Journal<\/em>, Dr. William Carpenter and Dr. Jim van Os discussed whether or not attenuated psychosis syndrome should be a DSM-5 diagnosis.  At issue is that the proposed diagnosis has been made only in research  settings attracting ill individuals at rates disproportionate to the  overall population; it is not clear whether field testing outside these  settings would result in the same conversion rates.<\/sup><\/p>\n<p align=\"justify\"><sup>At Parnassia Psychiatric Institute in The  Hague, we recently completed a multicenter study on the implementation  of a screening method for at-risk mental states in all consecutive  help-seeking patients accessing community mental health services for  nonpsychotic mental disorders&#8230;<\/sup><\/p>\n<p align=\"justify\"><sup>Of 3,671 consecutive patients, we  identified 52 [1.4%] with psychotic symptoms and 147 [4.0%] with at-risk  mental states in whom the nontrained community mental health caretakers  managing their care recognized neither psychotic states nor attenuated  psychotic symptoms. Thus, these patients went undetected by the  community caregivers who should in fact be among the important referrers  to specialized clinical research settings. In short, these patients are  missed in the traditional referral process.<\/sup><\/p>\n<p align=\"justify\"><sup>On the other hand, our screening detected  patients who later developed other severe psychopathology. This suggests  that the at-risk group may develop multiple severe illnesses besides  psychotic disorders, and it offered us the opportunity to destigmatize  mental illness for them. <strong><font color=\"#200020\">We tell our at-risk patients that they rightly  sought help because of a risk for developing severe mental illness in  the future. We never mention psychosis because we have found the at-risk  group to be very sensitive to the notion of psychotic syndromes. In  therapy we explain how dopamine sensitization affects perception,  cognitive biases, and affect, and we find that patients are less  distressed by their symptoms after receiving this information.<\/font><\/strong><\/sup><\/p>\n<div align=\"justify\"><sup>In the future, we should develop reliable  screening and detection methods with greater sensitivity and specificity  in order to detect at-risk mental state populations with higher true  incidences of severe illness. We recommend the nonstigmatizing name<strong><font color=\"#200020\">  &ldquo;pluripotent dopamine sensitization risk syndrome.&rdquo;<\/font><\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">Now from this month&#8217;s <strong><font color=\"#004400\">American Journal of Psychiatry<\/font><\/strong>, another synonymn: <strong>Psychosis Risk Syndrome<\/strong> = <strong>Attenuated Psychosis Syndrome<\/strong> = <strong><font color=\"#200020\">Pluripotent Dopamine Sensitization Risk Syndrome<\/font><\/strong>. I guess I missed the articles that established dopamine sensitization as an etiology for mental disorders, but I can see that we&#8217;ve moved pretty far from the plans back in 1980:      <\/div>\n<ul>\n<div align=\"justify\"><em><sup>The approach taken in DSM-III is atheoretical with regard to etiology or pathophysiological process except for those disorders for which this is well established and therefore included in the definition to the Disorder&#8230;<\/sup><\/em><\/div>\n<p align=\"justify\"><em><sup>Because the DSM-III is generally atheoretical with regard to etiology, it attempts to describe what the manifestations of the mental disorders are&#8230;<\/sup><\/em><\/p>\n<div align=\"justify\"><em><sup>This approach can be said to be &quot;descriptive&quot; in that the definitions of the disorders generally consist of descriptions of the clinical features of the disorders&#8230;<\/sup><\/em><\/div>\n<\/ul>\n<div align=\"justify\">So in 2011 we hear from from Dr. Kupfer&#8217;s Task Force:<\/div>\n<ul>\n<div><a href=\"http:\/\/www.dsm5.org\/about\/Pages\/faq.aspx\" target=\"_blank\"><u><strong><font color=\"#0033FF\">Why is DSM being revised?<\/font><\/strong><\/u><\/a><\/div>\n<div align=\"justify\">DSM has  been periodically reviewed and significantly revised since the  publication of DSM-I in 1952. Particularly over the past two decades,  there has been a wealth of new information in neurology, genetics and  the behavioral sciences that dramatically expands our understanding of  mental illness. Researchers  have generated a wealth of knowledge about the prevalence of mental  disorders, how the brain functions, the physiology of the brain and the  lifelong influences of genes and environment on a person&rsquo;s health and  behavior. &nbsp;Moreover, the introduction of scientific technologies,  ranging from brain imaging techniques to sophisticated new methods for  mathematically analyzing research data, have given us new tools to  better understand these illnesses.<\/div>\n<\/ul>\n<div align=\"justify\">I&#8217;m in the dark about what this has to do with the descriptive classification of Mental illnesses, or what great wealth of knowledge they&#8217;re referring to. Nor do I understand how considering the implications for the future or impacts on the family factor into the descriptive signs and symptoms of mental illness &#8211; or how synonyms, stigmatization, or making up palatable lies has anything to do with&nbsp; a rational diagnostic classification of mental illness.<\/div>\n<p align=\"justify\">Back in 1980, the DSM-III was intended to be something like a compass. It was meant to point the way away from ideology to descriptive science, and I expect Dr. Spitzer and friends thought that it would iterate towards a mutually acceptable base, similar to the medical classification of diseases &#8211; something that would knit psychiatrists of different ilks and other mental health disciplines into a cohesive unit in the treatment of mental illnesses. It has certainly <u>not<\/u> succeeded. Now we hear about advances in neuroscience, implications for the future, impacts on the family, and fictitious explanations &#8211; but not much about signs and symptoms of disease. When Dr. Frances first began to write about the <a href=\"http:\/\/www.psychologytoday.com\/blog\/dsm5-in-distress\" target=\"_blank\"><u><strong><font color=\"#0066ff\">DSM-5 in Distress<\/font><\/strong><\/u><\/a>, he was accused of being stuck on his version and being territorial. Frankly, it initially seemed a reasonable claim. But as time has passed, he has been beyond vindicated on that charge. We&#8217;re in his debt for alerting up to how far off the beam the whole enterprise was.<\/p>\n<div align=\"justify\">Dr. Kupfer&#8217;s DSM-5 has lost its way &#8211; or worse, never found it in the first place. The task undertaken in 1980 was daunting. If Mental Illnesses were&nbsp; easily classified descriptively, it would&#8217;ve happened a long time ago. Dr. Spitzer actually made a mistake back in those days by allowing certain interests to dominate the classification, particularly in the area of the Depressions and Manic Depressive Illness, but otherwise, his product was awkward but at least consistent. Dr. Frances made some mistakes too. He didn&#8217;t correct Spitzer&#8217;s errors and he allowed too many additions that were speculative and had unconsidered implications. But in both cases, the errors weren&#8217;t fatal. Dr. Kupfer has allowed his and his colleagues&#8217; neuroscience bias to replace the descriptive prescription, and allowed implication, impact, stigma, etc. to pervade the dialog. I know that <strong><font color=\"#200020\">Pluripotent Dopamine Sensitization Risk Syndrome<\/font><\/strong> isn&#8217;t headed for the manual, but it just illustrates how far afield we&#8217;ve moved. I signed the APA [<strong><font color=\"#200020\">American Psychological Association<\/font><\/strong>] <a href=\"http:\/\/www.ipetitions.com\/petition\/dsm5\/\" target=\"_blank\"><u><strong><font color=\"#0066ff\">Petition<\/font><\/strong><\/u><\/a> to reform the DSM-5. I hope you do too. But I don&#8217;t really think Dr. Kupfer&#8217;s Task Force can produce a usable manual. There&#8217;s just too much bias, conflict of interest, and misguided thinking to get the job done. I hope someone runs for president of the APA [<strong><font color=\"#200020\">American Psychiatric Association<\/font><\/strong>] on a platform of shutting them down and starting over&#8230;  <\/div>\n","protected":false},"excerpt":{"rendered":"<p>No, this isn&#8217;t another post about the Psychosis Risk Syndrome. I&#8217;ve been clear about my thoughts already. I oppose adding it to the DSM-5. This post is intended to be a post about psychiatric diagnosis in general: Should Attenuated Psychosis Syndrome Be a DSM-5 Diagnosis? by William T. Carpenter, M.D. and Jim van Os, Ph.D. [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-15941","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/15941","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=15941"}],"version-history":[{"count":17,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/15941\/revisions"}],"predecessor-version":[{"id":15963,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/15941\/revisions\/15963"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=15941"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=15941"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=15941"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}