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Psychiatric Diagnosis and DSM 5: Maps to Nowhere

Diagnostic Bible? Scientific Heresy

Diagnostic Bible: Scientific Heresy

If you are lost, forget being found with this bible…

You may think the new, long awaited DSM 5 psychiatric diagnostic manual would herald pointed improvements in the evolution of psychiatric science – like new brain information, new biomedical perspectives, new treatment strategies. Don’t be worried, you won’t have to change anything you are doing… it’s the same old 19th Century stuff, trimmed up to tweak the inadequate descriptive language, with no improvements there for evidence-based patient care, and no new science. Boring.

But Freud is happy. Affect based appearance diagnosis rules – measuring thinking/cognition is still out.

Remember: thousands are now treated daily for thinking problems – without thinking about thinking. With this “new bible” be forewarned: it will not save you.

The DSM-5 is not categorically ineffective

On a brief positive note you will appreciate this NPR review of the diagnostic evolution with childhood bipolar diagnosis – a significant problem addressed repeatedly here at CorePsych Blog as kids are regularly, automatically slammed with atypical antipsychotics rather than considering the biologic underpinnings of emotional explosions. Been there, done that.

Labels, not science, still prevail

See this brief description in the LA Times and you will catch the drift and controversy on these new, already outdated diagnostic maps. Our books are outdated simply because we aren’t learning how to read the brain images and the lab reports. All the names will change when we recognize gluten sensitivity, bowel dysfunction, and the abundance of metabolic imbalances that effect brain function.

The Earth is Flat! DSM 5 Points at the Tips of Icebergs – Only What You See

The tip-toe progress with these new superficial labels for office appearances misses altogether the complexity of new brain and body science. Neuroscience evidence is easily available, often paid for by insurance, and remains almost completely ignored by psychiatry. Real facts, not labels, will foretell the changes necessary for psychiatric practice, for treatment strategies to evolve with the rapidly evolving new science.

Neuroscience evidence changes thinking

Yes, these refined descriptions may help some talk about psychiatric matters with a bit less confusion, but the new DSM 5 conclusions are based almost completely upon 19th century vertical thinking, insufficient feedback with patients in the office, and questions that ignore modern neurophysiology and basic metabolic challenges that uniformly confuse medical practice.

Psychiatrists will remain speculative with dreams and fantasies, while hard evidence from molecular and cellular physiology remains in the closet – frequently derided as quackery. Interestingly, psychiatry is held to a different standard on evidence than the rest of medicine, as SPECT brain imaging and the measurement of neurotransmitter biomarkers is still derided as non-specific, while patently non-specific biomarkers, such as cholesterol screening, are accepted uniformly in general medicine.

It’s time for diagnostic change – but DSM 5 is already old news.

Your Comments Count

Let’s see what you think… please comment here and weigh in on your views of psychiatric diagnosis – look forward to hearing from you!
cp

45 Comments
  1. AS ALWAYS, we seem to be in accord (and I have too much to say about it for a quick comment). You are linked as Related Content to my DSM-5 response on ADDandSoMuchMore.com (“Gotta’ love the DSM-5 — NOT?”)

    JUST autoposted – I’m still on sabbatical.
    xx,
    mgh
    ~~~~~
    Madelyn Griffith-Haynie, CMC, SCAC, MCC
    – ADD Coach Training Field founder; ADD Coaching co-founder –
    (blogs: ADDandSoMuchMore, ADDerWorld & ethosconsultancynz – dot com)
    “It takes a village to educate a world!”

    • Thanks Madelyn,
      In new territories it’s always more fun traveling with companions who agree on where we’re going in the first place!
      Thanks for inclusion on the DSM-5 piece, it takes a village to look at Reality!
      cp

  2. “It’s time for diagnostic change”

    I listened to the NPR review of the diagnostic evolution with childhood bipolar diagnosis.
    With all due respect, I started laughing and thought now this is a perfect example of psychiatric quackery.

    The fact remains that without using the appropriate diagnostic tools which I consider to be “fresh laboratory brain data and biomedical initiatives” the chances for a correct diagnosis will be next to slim.

    Why? easy answer: the observation and determination of the patients diagnostic traits will be filtered through the perception of either, 1. the patient, 2. the parent, or 3. the psychiatrist. Now if 1, 2, 3 or all 3 have an undiagnosed or misdiagnosed mental health disorder, the patient is up a creek without a paddle in a big way.

    In the NPR pod-cast it is noted that millions, you got that, millions of children were misdiagnosed with bipolar.
    It doesn’t take a rocket scientist to do the arithmetic to understand why a tsunami of children were misdiagnosed with having bipolar.

    Obviously “someone” who diagnosed the child with bipolar needed a new prescription for their observation glasses.
    That “someone” lacked the common sense skill set to connect the diagnostic dots.

    Conclusion: “It’s time for diagnostic change” before society ends up suffering from their own self made mental health Apocalypse.

    My humble suggestion would be that every licensed mental health professional be encouraged to voluntarily submit their very own “fresh laboratory brain data and biomedical initiatives” in order to have an accurate and accountable filter before receiving or renewing their license to practice.

    • Oh yeah Susan, said so well, – and articulately expressing the thoughts and frustration of so many thousands of treatment failures. Needed: maps and a compass, defining and treating reality instead of make believe and dreams. We can’t get there from here.
      cp

  3. David Summers, a 37 year old MS patient from Murfreesboro, Tennessee was a score of 8.0 on the Expanded Disability Status Scale (EDSS) when he had the Combination Liberation Therapy and Stem Cell Transplantation at CCSVI Clinic in March of 2012. Having been diagnosed in 1996 he had been in a wheelchair for the past decade without any sensation below the waist or use of his legs.“It was late 2011 and I didn’t have much future to look forward to” says David. “My MS was getting more progressive and ravaging my body. I was diagnosed as an 8.0 on the EDSS scale; 1 being mild symptoms, 10 being death. There were many new lesions on my optic nerves, in my brain and on my spinal cord. My neurologist just told me: ‘be prepared to deteriorate’. I knew that he was telling me I didn’t have much time left, or at least not much with any quality.” David had previously sought out the liberation therapy in 2010 and had it done in a clinic in Duluth Georgia. “The Interventional Radiologist who did it told me that 50% of all MS patients who have the jugular vein-clearing therapy eventually restenose. I didn’t believe that would happen to me if I could get it done. But I have had MS for 16 years and apparently my veins were pretty twisted up”. Within 90 days, David’s veins had narrowed again, and worse, they were now blocked in even more places than before his procedure.“I was so happy after my original procedure in 2010. I immediately lost all of the typical symptoms of MS. The cog fog disappeared, my speech came back, the vision in my right eye improved, I was able to regulate my body temperature again, and some of the sensation in my hands came back. But as much as I wanted to believe I felt something, there was nothing below the waist. I kind of knew that I wouldn’t get anything back in my legs. There was just way too much nerve damage now”. But any improvements felt by David lasted for just a few months.After his relapse, David and his family were frustrated but undaunted. They had seen what opening the jugular veins could do to improve him. Because the veins had closed so quickly after his liberation procedure, they considered another clinic that advocated stent implants to keep the veins open, but upon doing their due diligence, they decided it was just too risky. They kept on searching the many CCSVI information sites that were cropping up on the Internet for something that offered more hope. Finding a suitable treatment, especially where there was no known cure for the disease was also a race against time. David was still suffering new attacks and was definitely deteriorating. Then David’s mother Janice began reading some patient blogs about a Clinic that was offering both the liberation therapy and adult autologous stem cell injections in a series of procedures during a hospital stay. “These patients were reporting a ‘full recovery’ of their neurodegenerative deficits” says Janice, “I hadn’t seen anything like that anywhere else”. She contacted CCSVI Clinic in late 2011 and after a succession of calls with the researchers and surgeons they decided in favor of the combination therapies.“I went to CCSVI Clinic in India without knowing what to expect” says David, “but I basically had one shot left and this was it. I was becoming pretty disabled, and I couldn’t think very clearly”. David was triaged with a clinic intake of other MS patients and had the liberation therapy on March 27, 2012. They also drew bone marrow from his hip bone in the same procedure. When he woke up from the procedure, he again felt the immediate effect of the widening of the veins. “In case anyone doesn’t believe that the liberation therapy works, I can tell them that this is much more than placebo effect.” The MS symptoms described earlier again disappeared. Four days later he had the first of the stem cell injections from the cultured cells taken from his hip bone during the liberation therapy. The first transplant was injected into the area just below his spine. Over the next 4 days he would receive about 100 million stem cells cultured in specific growth factors for differentiated effect.He was not quite prepared for what happened next. A few hours after the first transplant, he was taken back into his hospital room and was transferred to the hospital bed. “I’m not completely helpless when it comes to moving from a chair or a bed”, says David, “One of the things I can do for myself is to use my arms to throw my leg into a position to be able to shift the rest of my body weight over to where I’m going. But this time to my amazement, I didn’t have to pick up the dead weight of my leg and throw it. It moved on its own, exactly where my brain told it to go”. Shortly after his first stem cell transplant procedure, some motor function in his lower body had returned. “This was the first time in 10 years I had any sensation or motor function below my waste so it was quite a shock.”In the next month, most every motor nerve and body function has either returned or is on its way to recovery. “It’s been over a decade since I’ve had any power over my elimination functions. Now it’s all come back. I have total bladder control”. He’s also working out every day, following the physiotherapy routine given him by the clinic. “For years, I haven’t been able to work out without getting sick for a couple of days afterward. Now I have muscles popping out all over the place where I haven’t seen them since my MS became progressive…and I can work out as hard or as much as I want. With my ability to do the hard work my balance is improving each day and I’m able to take steps unassisted. I’m definitely going to be coming all the way back.”Dr. Av Gupte, the neurosurgeon who has now done over 2000 adult autologous stem cell transplants for various neurologic disease conditions says that the stem cells in David’s body will continue to work their healing process for the next year. “With the incredible progress I’ve seen so far, I won’t need a year”, says David. “It’s only been a little over two months and I have most everything back. I can’t wait to get up each day to check out my improvements. My right hand is completely back to normal without any numbness and the left is on its way. I have good strength in my legs now and I’m working on the balance”.Other MS patients treated with the combination therapy over the past 18 months have seen similar improvements but none have been as disabled as David. “If I can come back from where I was, most everyone with MS could too. For me, CCSVI Clinic has been my miracle and I can’t say enough about the doctors, researchers and staff who are helping me to recover. For me, MS was my previous diagnosis”.For more information please visit http://www.ccsviclinic.ca/?p=904

  4. Hi Dr. Parker,
    It’s been awhile since I posted anything as I was taking your advice and just observing my son’s behavior for awhile without drawing conclusions. He has been taking Intuniv for 3 months (2mg). We consulted with you after having his Neuro testing done through your office and we have been following the prescribed protocol you suggested in terms of supplements and diet. I have seen improvement in sleep regulation and a reduction in anxiety with better moods. What has not changed is his hot temper and that is what gets him into trouble at school and with friends. He is very impulsive and quick to react when an adult asks him to do something and he’s not in the mood. He is currently at a very small Montessori school where the teachers are more forgiving, but only to a degree. Today his teacher told me that his frustration level in math and reading are high which sets of his temper tantrums which are particularly bad and very disrespectful. Normally, he is respectful and has good manners etc… Just when I think things are getting better, we seem to take 10 steps back. I am growing frustrated and not sure what to do next. We went to see my son’s doctor last week and she did not offer any real direction. I sense she is giving up a bit since Jack’s is such a tough nut to crack. He seems to lack the ability to make an “executive” decision about his behavior regardless of circumstance or consequence. His reactions are almost always emotional and often based on misperceptions or over reactions to what is going on around him.
    My question is where to go from here. I can certainly schedule another Neuro test/consultation with you but my guess is that the test results will show more of the same. His Dr. said the next course of action would be to try an anti-psychotic to calm him down. I’m not sure where to go from here in terms of diagnosis and treatment options. Are we missing something? What do you suggest when faced with a young child who is resistant to traditional treatments. I was hoping to see better results with the combination of Intuniv, Celexa and the supplements in terms of his ODD, anger issues, but we seem to be sliding backwards again. I’m not sure if I should continue the meds, change the meds or take him off everything?? I love my son would do anything to help him if I could just figure out what it is I should be trying or doing next. Forgive my ramblings, but it’s hard to be concise with such complex issues. I’m guessing you get that a lot in your line of work. Thanks!!

    • Kate,
      Your question is such a good example of the process: Improvement, review, and adjustment. I do recommend we get on the phone for .5 hr and pull his chart to go precisely over the meds and details. Sometimes they need more inhibitory neurotransmitter precursors and sometimes you do have to bail and go for the Risperdal. Let’s talk in detail ASAP, and I can pitch in with your medical team out there. We don’t need to redo the NT testing to get a good picture of what to do in the current context, just need to detail the context and the specific reactions to interventions.

      Look forward to talking again,
      cp

    • Kate,

      I look forward to your posts and progress. Our sons sound soooo much alike. Wishing you the best and sharing in your struggles.

      Warm regards,

      Denise

  5. Great to rediscover your blog!

    I’ve never been a fan of the DSM … the labels I’ve been assigned, Bipolar II, etc. have only been useful in getting me started on finding a way to manage myself. The DSM is over prescriptive, anal, and flat out locks folks in.

    When I worked in a self help group with others who experienced mood dysregulation I found that those who made the best progress in managing their moods, were those who understood that a ‘diagnosis’ of what was then called Manic Depressive Illness was not a sentence but merely a guideline as to where to seek understanding and help.

    Your advice about the gut being important in mental health is spot on … a recent article in Scientific American Mind speaks of the gut as the 2nd brain.

    Thanks for your wisdom.

    LL

    • Lyle,
      Nice to hear from you up in snow country! It’s reassuring to see that others find the same challenges… the important next step for all of us, as you know: to become comprehensive in our assessments and treatments-
      cp

  6. I am my own Guinea Pig here. And the information that I accumulate is about to cause a rupture of my blood brain barrier! All joking aside, I have to say that this website has been the best so far, as I try to understand the Nuero facts that discuss transmitter disruption,etc…and the way the brain works in a way that even I can understand(that may be debated…my understanding? lol). I am obviously not on a level that would be beneficial here by my opinions, but I wanted to Thank You all for this chance I have to learn by Yours!

    Scott

    • Thanks back at you Scott, – and if you are a fly fisherman slip on your wading boots, as the details will soon deepen and become even more interesting – I will be writing about each of the neurotransmitter implications and functions as well as metabolic details about their precursors, and will be doing some easy YouTubes as well.
      Tnx,
      cp

  7. Psychiatry has a habit of forgetting that the brain is a body part, influenced by the rest of the body even as it is thought to be in charge of the entire organism.

    I have about had my fill of non-psychiatrists who look dumbly when confronted by, for example, an assertion that a hypothyroid condition can cause depression, and of psychiatrists who look blank when confronted by the same assertion.

    The patient is left to a.) do the homework, b.) make the connections, c.) request the appropriate lab work and treatment, and d.) suffer the consequences of the inadequacies of the available help. DSM 5 is just one area of trouble, though it surely is emblematic of some of psychiatry’s problems.

    Criticisms abound, from its unscientific, old fashioned and politicized labeling to its dependency on pharmaceuticals. My experience with medicine as a whole is that it asks far too few questions and listens to few of the answers for which it does ask.

    • Betsy,
      Thanks for weighing in so eloquently – great to hear your take from an esteemed member of the mental health community!
      cp

    • Indeed Betsy.

      And if you think simple-mindedness, myopia, and one-size-fits-all thinking is limited to psychiatry (not that you do, just a turn of phrase!), you might be surprised to learn that:

      —– Some sleep experts think that lack of sleep is the cause of all psychiatric illness (never the other way around) and, moreover, that stimulants work because people with ADHD are “sleepy”:
      http://www.medpedia.com/questions/623-why-do-stimulants-work-for-adhd

      —– Women should be given 1200 mg calcium daily, no questions asked:
      http://www.medpedia.com/questions/5-how-much-calcium-should-a-23-year-old-female-consume-every-day

      • Deep science is so invigorating! Do those guys work on an assembly line? Sounds robotic to me…
        cp

      • Ah, yes. Which would be why stimulants help some people with AD/HD to sleep.

        In the last few weeks alone, I have had to deal with a doctor who:
        eyed a thin 17 year old who eats zero foods that are not nutrient rich and ordered up a slew of lab tests, all of which came back within “normal” limits with a couple of exceptions that are easily explained and easily corrected,
        ignored completely the fact that said patient is in such poor health overall that there are days she never rises from the couch and has to be awakened for food, drink and medication;
        insisted on a screening test for a disease the patient could not possibly have (details private, take my word for it, but if the patient won’t urinate, the test cannot be run, haha);
        applied, for the fourth time, pressure to vaccinate with a new vaccine for which there are no long term safety data, a massive marketing program, high numbers of adverse events reported, as well as no benefit over what regular medical checkups can provide;
        called the consulting psychiatrist in a temper, declared the Vyvanse dose was too high, the weight was too low, and implied the psychiatrist was negligent at not noticing an eating disorder.

        And that is just one doctor. The psychiatrist, level headed and knowledgeable – more so than most, anyway – requested an extra visit with the patient to demonstrate due diligence (at our expense) and shared his impressions as well as recommended an increase of Vyvanse for the first few days of the menstrual cycle, per the patient’s request.

        He further stated that while anyone on stimulants for 9-10 years is probably not suffering from appetite suppression anymore (!!), he also believes that the benefits of stimulant medication can sometimes outweigh the potential problems of weight loss, provided the diet is good. As he put it to the patient, what your doctor doesn’t seem to know is that for you to even be here and speaking for yourself is a very big deal. Moreover, it has never been my impression that you have a body image problem or have the cognitive tendency to keep track of portion sizes.

        The patient agreed. LOL.

        • Betsy,
          What a stand up guy that psych is! Give him a high five for taking the message to the people who don’t get it! Sad but too often true… I never comment on anything I know nothing about – and yet everybody and their brother is on the gossip train with ADHD. So many experts, it’s simply amazing. ;-)
          cp

  8. Well said, Dr. Parker.

    It didn’t help, in my opinion, that experts with ties to pharma (grants, etc.) are essentially being excluded from the DSM committees. Who does that leave? Perhaps psychiatrists who are even more hidebound in 18th Century thinking. Seems little more than pandering to public misinformation on this topic.

    Of course, given that so many psychiatrists have failed to understand medications (not to mention the host of metabolic processes that can exacerbate or mitigate brain dysfunction) and so have often mis-prescribed them, the public is understandably growing more distrustful of psychotropic medication. I hope we don’t end up throwing out the baby with the bathwater.

    I learned all I needed to know about APA psychiatrists by attending the conference in SF last year. Not one mention of ADHD (I got the feeling most of these psychiatrists saw it as too “simple” to treat, with stimulants, and somehow beneath their investigative prowess….ha!). But there was lots of “self-medicating” with the dramatic narratives around patients who have Borderline Personality Disorder. Sheez.

    • Gina,
      Interesting pharma/DSM point – one with which I completely agree. In fact the whole picture of diagnostic confusion comes more into focus with your observation regarding who-is-doing-the-observing. Naming arises only from what you know, not from what you don’t know. The pharma folks are much more on board with the silliness of labels, as they bring deep complexity to the table every time… er, most of the time.

      Reminds me of smoking cigars in Philly at the psychoanalytic meetings there, thinking of the levels of superego impairment whilst the toxic state of the body remained in complete, utter denial. We could talk quite explicitly about orgasms and masturbation, but remained in darkness regarding frequency and consistency of #2. In fact, I think the more we smoked those Bances Double Maduro cigars [my favorite at the time – now avoided like the plague] the more the sexual discussion evolved. But I wasn’t inhaling. Didn’t have to. Floated out of the chair on a blue nicotine cloud.

      Now it becomes more clear, as I do believe these DSM 5 discussions do appear to take on the luster of self stimulation on the very topics that have always registered as loaded with troubling complexity. It seems that complexity drives more denial and new labels with more meetings. Bipolar, Borderline Personality, Autism, and Asperger’s – all exceedingly complex diagnostic conditions with inevitable associated biological complexity, and associated unpredictability with meds – great fodder for more naming ceremonies – and more speculative psychoanalytic papers. – Too many abstractions away from plain talk, and available science.

      Thanks for weighing in with your usual dissecting microscope!
      cp

      • Bances Double Maduro cigars! lolol!

        Truly, I was astounded, sitting in those presentations at APA on Borderline Personality Disorder as speakers, with Sherlock Holmes-like fervor, would describe the great mysteries of these patients with such poor prognoses. The bullet points in the Powerpoint presentations often read as if they were straight from ADHD diagnostic criteria, but would ADHD ever be mentioned? No. Because, presumably, that would be reducing their Great Art and Powers of Detection to a few lousy molecules.

        I’m also reminded of a man who’d been in weekly psychoanalytic therapy for 10 years, with little progress. He finally came upon some information about ADHD, grew convinced that he might have it, and asked the psychiatrist about it. The psychiatrist finally relented in agreeing to prescribe a stimulant, with this proviso: The client had to bring something else interesting to talk about in their weekly sessions — a good book read or movie viewed. It was all about him, after all.

        • And get this Gina, the new polarity, you heard it first here, is not between traditional and functional diagnoses, nor is it simply between biologic and psychological assessments, but rather the inelegant dichotomy of shallow vs deep – thinking that is. ADHD is almost uniformly perceived as too shallow, too commonplace, and not worthy of thoughtful analysis. I can tell you from experience, though I didn’t know him personally, Freud would not be happy with ADHD. This CorePsych note encapsulates some of my experience with years of training with some absolutely great mentors.

          Borderline personality, and the associated ‘unmanageable cognitive abundance,’ is so deep because those with borderline traits think of so many bizarre topics [those topics undoubtedly must have some meaning] – it’s a sea of seductive abstractions with happy layers of smoke and speculation – so much fun, so intellectually exhibitionistic. Kinda like the Dallas Cowboy Cheerleaders of the Mind. Wanna dance?

          Reminds me of an International OCD conference on the island of Madeira many years ago with a similar reaction when I shoulda kept my mouth shut.
          cp

        • In the course of an analytic style training psychotherapy, my doctor told me he thought my brain was wired funny. He further said he didn’t think our work was going to change that, nor did he think that would even be desirable, but he did take note.

          Of course, later I learned about that very wiring, and agree there isn’t anything psychology can do about it. But I think the owner of the brain is in a better position to determine what would, and would not, be desirable. I have often wished it were possible to trade mine in for a standard issue brain, and would gladly give up some IQ points in the bargain, thank goodness I have them to spare. As it is, I do not enjoy the enhanced intelligence they were supposed to afford me because they are endlessly occupied with management functions that ought to be handled by the day crew.

          • Betsy,
            Aren’t you the lucky duck! Two docs who got it right out of the box! Gotcha on the day crew… need a few heavy lifters to keep after the cracks in the foundation!
            cp

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