{"id":21234,"date":"2012-03-16T16:00:08","date_gmt":"2012-03-16T21:00:08","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=21234"},"modified":"2012-03-16T21:46:43","modified_gmt":"2012-03-17T01:46:43","slug":"to-pick-up-the-task","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2012\/03\/16\/to-pick-up-the-task\/","title":{"rendered":"to pick up the task&#8230;"},"content":{"rendered":"<div align=\"justify\">I finished my psychiatry residency in 1977 and was in psychoanalytic training traveling between Atlanta and New York biweekly and busy enough for several people, so I was barely aware of the DSM-III Revision that would have such an impact. After it came out, people spoke of little else, and I never got it. So I particularly appreciate Dr. Carroll&#8217;s note about its history: <\/div>\n<ul>\n<div align=\"justify\"><sup>&quot;For that matter, DSM is not even a diagnostic manual. Its command of diagnostic process is weak. And it certainly has never been a scientific document. Since the days of Gerald Klerman as Administrator of ADAMHA leading up to DSM-III it has been clear DSM is mainly an administrative manual. It was not designed for actually making diagnoses. It is designed to ensure that the diagnoses made by clinicians conform to a minimum symptomatic data set for reimbursement purposes. All other claims are just hand waving and humbug.&quot;<\/sup><\/div>\n<\/ul>\n<div align=\"justify\">In Mental Health and Psychiatry, particularly in that era, we were used to shifting and competing ideological arguments. At the time, I would never have predicted that the DSM which, as Dr. Carroll says, was administrative, would occupy the center of a paradigm change with so many ramifications. It reminded me of another incident in my life when I was called on the carpet in the Air Force for a violation of regulations. I had no idea what regulation I&#8217;d violated. It was the base telephone book which, as it turned out, was considered a <em>regulations manual<\/em>. Who knew? But I think that&#8217;s the level of the DSM-II in those days &#8211; <em>look-up<\/em> codes for insurance forms, little more. At least that&#8217;s my memory.<\/div>\n<p align=\"justify\">It didn&#8217;t take very long to figure out that the DSM-III was much more. The first part was easy. It was anti-psychoanalysis and anti-psychotherapy and since that&#8217;s what I came into psychiatry to learn about, my orientation was a kiss of death and I exited <em>stage left<\/em> quickly. It&#8217;s hard to convey what that was like back then, because there&#8217;s been so much change. In my mind, psychiatry and the various psychologies of mind were in no way a dichotomy. There were the &#8216;diseases&#8217; of psychiatry &#8211; Schizophrenia, Manic-Depressive illness, Melancholia, etc. that I thought of in the same medical way I&#8217;d thought of physical diseases as an Internist. And there were psychological causes of mental illness that were &#8216;dis-eases&#8217; of the mind &#8211; the thing I&#8217;d come to learn more about. I was as interested in one as the other, in fact, would&#8217;ve not even made that distinction at the time any more than I would distinguish medical diseases of structure [coronary artery disease] from metabolic diseases [diabetes mellitus]. But found myself in a world where that kind of approach was no longer possible. And it all hinged on the DSM-III, which turned out to be a <em>regulations manual <\/em>rather than a <em>look-up book<\/em>.<\/p>\n<p align=\"justify\">It was a paradigm shift, sure enough. The shift, as I understood it, was to a purely descriptive, evidence-based diagnostic system. I was used to that from Internal Medicine. Many areas had formalized diagnosis in that way: Rheumatology, Cardiology, Diabetes. Criteria lists that were followed rather rigidly. I had found the clarifying. They had been carefully taped into my &quot;ectopic brain&quot; [those bulging little black books training physicians carry around for reference] &#8211; another kind of <em>look-up<\/em> book. But the shift was more than that. The DSM gradually came to be a <em>Diagnostic Manual<\/em> &#8211; meaning a <em>How To<\/em> book, essential for making the diagnosis &#8211; more <em>textbook<\/em> or <em>rule book<\/em> than a <em>coding look-up book<\/em>. It defined Diseases [Disorders]. All kinds of things were keyed to it: reimbursement, disability, FDA Approval, Clinical Trials and other research, medication approval, actually everything. And that just happened. I don&#8217;t recall a vote, or a declaration on that point. I just remember seeing that it occurred in an epidemic or a tsunami fashion parallel to the regulatory changes in all of medicine that came with Medicare, Medicaid, and Managed Care. It became our <em>Diagnosis Regulations Book<\/em>, and the DSM-IIIR, DSM-IV, and DSM-IVTR continued the tradition.<\/p>\n<div align=\"justify\"><strong><font color=\"#200020\">Something New:<\/font><\/strong><br \/>The DSM-5 as proposed is another paradigm shift &#8211; not an extension of the DSM-III, DSM-IIIR, DSM-IV, and DSM-IVTR tradition. It&#8217;s something else, and has been from the starting gate. This new paradigm has several dimensions:<\/div>\n<ol>\n<li>\n<div align=\"justify\"><strong><font color=\"#200020\">A Treatment Manual:<\/font><\/strong><br \/>Which seems to me to be an extension of the <strong><font color=\"#200020\">Algorithm Movement<\/font><\/strong> that lead to the Tri-University Guidelines, TMAP, STAR*D, IMPACT, TORDIA, TADS, CO-MED, EMBARC, etc. The idea is that Diagnosis [eg MDD, Bipolar, Schizophrenia] is welded onto a specific treatment sequence or pathway. When the DSM-5 Task Force speaks, they usually include treatment in the rationale for a diagnosis.<\/div>\n<ul>\n<div align=\"justify\"><sup>&quot;<em>If patients are suffering not from normal sadness or grief, but are suffering from a severity of symptoms that constitute clinical depression, and need intervention, and they want help, that they should not be prevented from getting the appropriate care that they need because somebody tells them that, well, this is what everybody has when they have a loss.<\/em>&quot;<\/sup><\/div>\n<\/ul>\n<\/li>\n<li>\n<div align=\"justify\"><strong><font color=\"#200020\">The Biological Basis of Mental Illness:<\/font><\/strong><br \/>While it was obvious that the most vocal supporters of the DSM revisions were psychiatrists who were primarily interested in psychopharmacology and matters biologic, they stuck to the descriptive moniker in the earlier revisions. From the start, this one has been different, beginning with Dr. Kupfer&#8217;s book laying out a blueprint for the DSM-5. They envisioned lab tests and biomarkers that would define diagnosis precisely as in the rest of Medicine. Even though those things didn&#8217;t materialize, the trajectory is little altered. Dr. Insel&#8217;s <em>Psychiatry<\/em> as <em>Clinical Neuroscience<\/em> is just around the corner. They even propose including the biology part in the definition of mental illness:<\/div>\n<ul>\n<div align=\"justify\"><sup>&quot;<em>A behavioral or psychological syndrome that reflects an underlying psychobiological dysfunction.<\/em>&quot; <\/sup><\/div>\n<\/ul>\n<div align=\"justify\">And the biological\/medical bias is barely under the surface in what they say publicly:<\/div>\n<ul>\n<div align=\"justify\"><sup>&quot;<em>Darrel Regier, the psychiatric group&rsquo;s research director, characterized critics as being unconvinced medical treatment is better than counseling.<\/em>&quot;<\/sup><\/div>\n<\/ul>\n<\/li>\n<li>\n<div align=\"justify\"><strong><font color=\"#200020\">Public Health and Preventive Medicine:<\/font><\/strong><br \/>This part is everywhere. We used to treat the patients that came to us, but now there&#8217;s a background that almost feels like &#8216;trolling for patients.&#8217; But in the DSM-5 Proposals, nowhere is it more obvious than in the Attenuated Psychosis Syndrome where the implication is that we should preemptively treat people who &#8216;might&#8217; develop a mental illness.<\/div>\n<\/li>\n<\/ol>\n<div align=\"justify\">I see every bit of that as a simplification of human experience. Formal diagnosis only informs treatment. People have many more unique dimensions than those attended to in the DSM-anything. I, of course, don&#8217;t agree that biology directly underlies all, or even most, mental illness, and I&#8217;m definitely one who is &quot;<em> unconvinced medical treatment is better than counseling.<\/em>&quot; That&#8217;s a gross logical fallacy known as <strong><font color=\"#200020\">The False Dichotomy<\/font><\/strong>. Neither is &#8216;<em>better<\/em>.&#8217; And frankly, I don&#8217;t see the application of Public Health and Preventive Medicine in mental health the same way. To me, those principles are part of the social reforms that go after the poverty, social dysfunction, and addictions that have such a devastating impact on the developing child. I don&#8217;t think it has to do with loading up sick people with antidepressants because they&#8217;re unhappy about being sick, which is a frequent KOL suggestion.<\/div>\n<p><\/p>\n<div align=\"justify\">And it&#8217;s not lost on me that every single piece of the new DSM-5 paradigm leads to the same thing, the medication of an increasingly large portion of the population. I came into psychiatry because I wanted to be able to spend the time it took and learn what I needed to learn to help the mentally ill people I saw make substantive changes in their lives and futures. If all it means is just giving them symptomatic medications, I needn&#8217;t have come. I already knew how to do that as a medical doctor. And if the DSM-5 Revision as it now stands becomes the standard, psychiatry as I&#8217;ve known and respected it will disappear. I hope there will be someone there to pick up the task&#8230;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>I finished my psychiatry residency in 1977 and was in psychoanalytic training traveling between Atlanta and New York biweekly and busy enough for several people, so I was barely aware of the DSM-III Revision that would have such an impact. After it came out, people spoke of little else, and I never got it. So [&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_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-21234","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/21234","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=21234"}],"version-history":[{"count":16,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/21234\/revisions"}],"predecessor-version":[{"id":21275,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/21234\/revisions\/21275"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=21234"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=21234"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=21234"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}