Tuesday, May 17, 2011

DSM of APA an Ivory Tower monstrosity that harms more than helps in conceptualizing and treating mental illnesses

I had submitted the following article to a mainstream psychiatric journal, pointing to how conceptualizing and treating mental illnesses through the use of rating scales and DSM diagnostic criteria hinders more than aids treatment. As expected it was rejected. So I am putting it on the blog. It is rather long but anybody who is seriously interested in psychiatry will find plenty of meat in it.

Do the “Real-World” Field trials of DSM diagnostic categories have anything to do with the Real world of Psychiatry?

Recently I read in Psychiatric News (1) that Dr. David Kupfer, the chairman of the DSM V task force, is now conducting “Real-World” Field Trials of DSM diagnostic categories to test whether they are useful to clinicians, and it will be done through questionnaires and rating scales.

I hate to say it but it is a slap on the face of real world clinicians. In real world of psychiatric practice anybody who wants to make sense of his patients’ complaints rather than cataloging them to reach a critical threshold to clinch a diagnosis does not use rote questionnaires, does not use rating scales, and does not use the DSM system of classification.

Mental illnesses should not be conceptualized the way we do with physical illnesses and should not be approached using structured formats and should not be put in rigid diagnostic categories the way DSM does. Furthermore, using rating scales to elicit and judge the intensity of patient’s symptoms is a sure way to ruin any prospect of understanding as to what the patient is trying to say through them and how they fit in with his overall mental world. The DSM system starts with the presumption that patients’ report of their nebulous and ever changing mental states alone is enough to rely upon as to what is wrong with them. In reality it is very difficult for patients to report their problems with any degree of reliability. The problem becomes even more complex when we observe that while patients when reporting about physical illnesses do their utmost to have their verbal reports correspond to what is ailing them, mental patients are as likely to use their words to hide and mislead you as to what is emotionally and behaviorally troubling them. They are as committed to hiding from themselves as from their doctors as to what are their mental issues. To base a diagnostic system of mental illnesses solely upon what the patient reports, accepting everything on face value, is like building a Taj Mahal on a foundation of shifting sands. No wonder the size of the DSM diagnostic categories is going through the roof.

Unlike physical problems, mental complaints are exceedingly context laden and cannot be understood without paying attention to the continuity of thoughts processes, the emotional nuances accompanying these thoughts, and the non-verbal cues the patient gives while reporting. A clinician cannot attend to these if his attention is divided between reading aloud the questions from his rating scales, selectively listening to patient’s responses to fit in with what the rating scale expects, making up his mind when to cut short the patient to proceed to the next question, and trying to decide with every answer as to what quantitative option between 1 to 6 best fits the qualitative utterances of the patient. Structured formats by their very nature discourage open-ended narration by the patient and without there is little possibility of going in to the deeper structures of the mind where the meat of the real world of psychiatry lies.

A movement started in the early 1960s, beginning with Present State Examination (PSE), and which was quickly followed by Research Diagnostic Categories (RDC) and the Third Diagnostic and Statistical Manual of American Psychiatric Association (DSM III) that ad hoc decided that mental illnesses in essence are not different than physical illnesses.

Unfortunately there are several fundamental differences between mental and physical illnesses. Only two can be taken up here. When a person reports a physical problem to the physician there is little disagreement between the two as to what constitutes the illness and what should be the treatment. If there is a fracture of the foot the doctor and the patient will rarely disagree over the X-ray findings and even more rarely disagree over the advisability of treating it. But the matter is quite different with mental illnesses. Not only as to what is wrong with the patient, but how to approach it. Take for example a young patient of mine who suffers from obsessional neurosis and is plagued with images of harm coming to her sister such as seeing her younger sister falling off the edge of her school playground. One day she said that from henceforth she will communicate with me only in writing and that too by email and I could just call in to the pharmacy her prescriptions. When told that this decision is another attempt to prevent her hostility to show itself in her communication in my office and should be viewed as a symptom, she got very upset and claimed that communicating through writing instead of speaking is not a symptom but a more reliable and objective method of describing her problems. She would undoubtedly love structured formats especially if she can do them through the anonymity of the Internet.

The above is an extreme case but it appears that when it comes to reporting mental problems our mind is divided. One part wants to reveal the facts and join hands with the doctor’s endeavors, while the other does it’s utmost to maintain the status quo and does so by distorting the true state of affairs. This is because our desires and impulses that make us mentally sick [by becoming pathologically strong] are generally anti-social in their aim, while from earliest childhood we are taught to put our best foot forward when talking and revealing about ourselves to others and we loath to reveal the unacceptable aspects of our mental life. Any psychiatric interviewing technique that ignores this fundamental “hypocrisy” of human mind when reporting about itself that makes our speech as much an instrument of accurate communication as an instrument of deception e cannot go beyond scratching the surface.

To make matters more complicated mental diagnostic categories unlike physical disorders have no independent existence. They are inexorably intertwined. Mental complaints do cluster. But while individual complaints are pregnant with meaning, the clusters have little clinical usefulness. As soon as you give a name to one such cluster of your patient’s problems, and gear up to resolve it en masse, say depression, you find that there is another cluster lurking right behind which warrants putting the patient in to another category like obsessive compulsive. It you listen some more you may find he is hysteric in his body aches and pains and anxious in his chronic expectation of harm, paranoid in his belief that people are always ill about him, sociopath in the way he files his taxes , pervert in his fantasies, and an outright psychotic in his nightmares. And even these clusters may be just scratching the surface. One often finds even more clusters, which the patient was barely aware of when he first came to you, that he is willing to examine once his thoughts and emotions were allowed freer expression in a carefully nurtured therapeutic alliance.

Now if one starts using rating scales for all these clusters, as our colleagues from their Ivory Towerswould like us clinicians to do, our therapy sessions would comprise of nothing more than running ragged from one rating scale to another for the clusters of these patients have no beginning or end.

One can understand why researchers love rating scales. They need symptom clusters to correlate with their “biological markers”. They would give anything for these clusters to appear in isolation and be ironclad entities. Presence of multiple clusters is a nuisance, or at least an unwelcome confounding variable, to their work. So they have a natural bias to ignore the existence of clusters which they are not looking for to correlate with their “biological marker”. And of course rating scales are indispensable for epidemiological and pharmaceutical studies where the whole objective is to crunch out numbers and not understand the meaning behind patient’s complaints.

For the clinician, however, the problem is very different. As soon as he pays attention to symptom from one cluster, the patient tends to make a getaway into another cluster. Let me illustrate this with an example.

A woman, who was hypochondriacally preoccupied with breast cancer, on being confronted that it is a punishment for death wishes against her mother - who did have breast cancer when the patient was a teenager and which she survived – stopped her obsession with cancer and went into a panic attack. When the panic was interpreted as an attempt at flight from dealing with her ambivalence towards her mother with whom she still lives at the age of 51 despite having a boyfriend she developed a migraine headache – a hysterical somatization. Along with headache came another somatic symptom – an attack of colitis – a conversion of her psychic anxiety into an autonomic somatic behavior. When she came out of the restroom she claimed could no longer drive home because her agoraphobia has come back with a vengeance and she cannot be trusted not to hurt somebody on the street. On receiving alprazolam she felt confident about driving, but only when her original hypochondriacal preoccupation with breast cancer returned and blocked out all other “clusters” from her consciousness.

Can such a patient’s problems, and virtually all patients are as complex when examined closely, be really handled with the medium of rating scales or can be even rightly viewed as clusters of illnesses that should be handled en masse? If one still says yes, he is either a hypocrite or has no feel for the real world of mental illnesses.

The trouble with ivory tower folks who spend most of their time doing biological research, collecting data through the medium of rating scales, and teaching residents journal knowledge is that the pride they feel in their lofty mission often misleads them into believing that the average private practitioner is too ill trained to correctly assess whether the patient is improving or worsening without the help of rating scales.

This is preposterous. Even a marginally good clinician within minutes of listening to his patient, whether done with or without the help of rote questions, can tell if the illness is getting better or worse. There are of course bad clinicians, and plenty of them, and they do have vested interest in seeing the patient the way he is not, usually to justify keeping them on unnecessary medications and treatment, but such doctors will make such errors of judgment with or without rating scales.

Judging patient’s improvement or worsening is not a rocket science, and the last thing we clinicians need is to have these rating scales become mandatory in assessing progress or lack of it in approaching psychiatric problems which ivory tower folks cannot emphasize enough is the wave of the future. It will be the final nail in the coffin of qualitative approach in treating mental problems. And the irony is how little these rating scales enhance our clinical judgment. Psychiatric symptoms move in tandem. If a patient’s anxiety lessens generally his depression will too and if an antipsychotic is effective in a patient is will be as much with positive as with negative symptoms. It is simply impractical, and outright counterproductive to approach these patients with stack of rating scales and rob oneself of the valuable clinical time to decipher the displacements that underlie mental symptoms before they emerge in consciousness.

Another problem with using rating scales is that it starts with an a priori assumption as to what kind of complaints the patient is going to bring to a session and what rating scales one should take out of the drawer to do the job. A person who gets diagnosed as Major Depression or OCD will session after session will get assessed with HAM-D and Y-BOCS respectively. But is this fair? By using such stock questionnaires one may very accurately assess the intensity of a few symptom clusters but in the process one may completely miss out on seeing the uniqueness of the patient’s illness. The approach is truly the proverbial case of missing the forest for the trees. Structured approaches simply do not create the right ambiance for capturing the vastness, as well as the deeper strata, of patient’s mental world. For example a patient of mine who was initially diagnosed as suffering from Major Depression and Generalized Anxiety Disorder and should have been approached with the rating scales for these two disorders per current academic recommendations under the grip of severe resistance which had to be carefully dealt with told me that every night he must open and close his refrigerator, and flush his toilet, four times each, before he can fall asleep, because the alternative would be the death of all the four members of his family - his parents, his sister and himself, while he lays sleeping.

Most of the meat in psychiatry lies in such subtle details, which have little to do as to which diagnostic category the patient belongs to. Also such subtleties, the patient will never let you in if he senses that the primary agenda of the session is for the doctor to rush from one question to the next to get over with his rating scales. One of course can argue that the therapist can first rate the symptoms and then go on with the business of dealing with them per his theoretical persuasion. But in practice this never works. The shallow interpersonal connection that exists between the patient and the therapist when the therapeutic alliance is established through reading of the questions out of a manual of rating scales mars the completely non-judgmental open-ended ambiance that must develop in the session before the patient will take courage to tell you something as complex as the meaning of an obsessive act of closing and opening of the refrigerator four times “magically” averts the death of the four members of his family in his psychic world. A long time back Madagascar (2) did some interesting research and showed that what a patient will tell in a therapeutic session depends highly upon the degree of affect-laden empathic connection that develops between him and the therapist. Reading questions out of rating scales is no way to develop any such affect-laden empathy. It is easy to get on the same page of the rating scale manual but a lot harder to the same pages of mental complexes where the patient’s psychic blocks exist.

Since mental symptoms when viewed as clusters and dealt with en masse tell us so little about the patient’s real difficulties in his psychic and real world and lend themselves so meagerly for resolution respectively, is there any benefit to giving diagnostic labels to mental patients?

Yes, there are benefits. Not great benefits now, but certainly there are some. First of all we have no choice but to use diagnostic rubrics to make a crude working categorization of patient’s overall difficulties, and not only just for our own thinking but to communicate with other professionals and third parties and to a minor extent with the patient who, more familiar with the world of physical illnesses, would like a diagnostic label as to what is wrong with him. Our reimbursement depends upon billing with succinct medically sounding diagnoses with their own diagnostic codes. Then there is the real world of other medical specialists, primarily family practitioners and internists, who want to have an elementary working knowledge of psychiatry without any interest in the metapsychology of these illnesses, so they can prescribe half a dozen or so psychotropic medications that they are familiar with. Let us not forget treating mental problems constitutes a significant portion of their income. One may mention in passing though that such a superficial and drug -oriented quasi-psychiatric practice is usually substandard care, and in my experience these non-psychiatric physicians more often than not give either too little or too much psychotropic medications and by their ignoring of the psychological dimension, in long run, they do more harm than good for psychiatric. Training more good psychiatrists instead of training non-psychiatrist physicians to treat via using psychiatric rating scales is the more correct approach to the overwhelming presence of mental illnesses. The legal system, including disability determination and workmen compensation organizations, and Managed Care behemoths all need diagnostic labels to do their work. However, let us not fool ourselves that these people have any real interest in finding out as to what is really wrong with these patient and their love for ironclad diagnoses and the multi-tiered axes of DSMs arises because it makes it easier to deny benefits, joust with adversaries, and hone out deals and quick judgments with such a simplistic diagnostic approach.

While we cannot do away with diagnostic labels we can certainly do away with pretending that arriving at such diagnoses is a very important part of psychiatry. The hoopla that has been created around the development of DSM V and how the task force participants are fighting tooth and nail as to which symptom clusters deserves distinction of full fledged diagnosis – and now there are about 500 of them – and which should be denied access to the schema reminds one of congressional infighting over different pork in passing bills and give a wrong impression to trainees and even trained psychiatrists that arriving correctly at these DSM based diagnoses is the crux of psychiatry. But in the real world we could care less as to what diagnoses our patient has garnered. For we know that once treatment proceeds symptoms from across the board of those diagnostic categories will start emerging with their own contextual logic without any regard for the diagnostic categories.

As for the other Axes of DSM their usefulness is even more suspect. There is no real justification to give personality disorders a separate axis. It saw the light of the day to create niche for a few chosen psychiatric researchers who were big in the field in the late Seventies. But they are now gone, or have turned quite old, and the Axis’s usefulness has now fallen to just denigrating difficult and irritating patients as borderline or histrionic or sociopath, with other personality disorders almost never getting mentioned. Furthermore real clinicians don’t approach patients’ personality disorders with one set of therapeutic method and his other psychiatric problems with another. The third axis is a joke as well. Psychiatrists add one or two of them as an afterthought, without doing any physical examination. They are, in the real world, to use the vernacular, half-ass impressions about patient’s physical illnesses. The imprecision with which these diagnoses are arrived at without any clue as to how many of them should be mentioned behooves that such an approach towards physical illnesses should be abandoned by psychiatrists. Just like an orthopedician feels no compulsion to put the patient’s cardiac or dermatological illnesses on a separate axis, though he would not operate on a patient in an advanced Congestive Cardiac failure or on a psoriatic joint, I see no need for a special axis for physical illnesses for psychiatrists. If a physical illness requires major psychiatric intervention it can be as easily listed as another diagnosis alongside others ones which are outright psychiatric. The fourth and fifth axes are quantitative measures to assess the strength of the stressors and the gravity of patient’s illness respectively. But in practice they have become a cat and mouse game between psychiatrists and third party payers for only a fool will not give his patient very high scores in the beginning and then show gradual improvement to keep getting more sessions authorized. It may be worthwhile mentioning here that it is not just playing games with the last two Axes, but the entire psychiatric documentation has become a rote game. One is expected to do two, or at most three, pages long initial evaluation and then two or three line perfunctory mental status statements on subsequent visits, all done mechanically with the sole purpose of protecting oneself from potential lawsuit and giving justification to write prescriptions.

The multi-axial system makes the profession look very good and one has to concede that if it does not dazzle the outsiders it at least baffles them to wonder if our field is not more complex than any rocket science. However, the truth is that the multiaxial fanfare is a weird imposition upon the practitioners with no practical benefits.

It is time we move away from considering making correct categorical diagnoses using the DSM system as a very important aspect of psychiatry and the first step in this direction would be the doing away for good the last four axes. It will be the first blow on our pretensions that by writing those pompous multi-axial diagnoses we have written something very useful about the patient.


1. Kupher D. Read-World field trials: Next step in DSM-5 process. Psychiatry News. Oct. 1 2010, 45: 19, 2.

2. Matarazzo, JD: Prescribed behavior therapy: Suggestions from interview research. In A.J. Bachrach,ed., Experimental Foundations of Clinical Psychology. New York :Basic Books. 1962: 471-509.

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