In a recent [April 7] posting in The Psychiatric Times David Fogelson discussed What's New in Psychopharmacology and addressed the evolution of diagnostic coding practices as they related to new brain science discoveries. The article suggested we are moving beyond labels and the process of simple identification.
I thought you might be interested in the comments that I left over there regarding Dr Shorter's remarks in the Washington Post indicating we are quite lost in diagnostic imprecision – my quick take: We really must move beyond the intellectual passivity of collecting and identifying butterflies.
The Arrested Interface: Science and Practice
Regrettably, Shorter's comments regarding psychiatric diagnostic labels do typify the rank and file of psychiatrists who continue to condemn forms of hard brain-function evidence [such as SPECT imaging and other forms of available laboratory testing] in favor of phenotypic perceptions that encourage vertical diagnostic and management systems.
DSM-5 is an excellent example of the prevalent, indeed ubiquitous, developmental arrest in regards to retooling our superficial labeling process without evolving the underlying, evidenced-based molecular and cellular diagnostic processes that reference brain and body functional neurophysiology. Evidence is there, but collectively we simply don't approve of it.
Denial of this evolving science is the far more prevalent tone – understanding and balanced scientific inquiry is sadly lacking. Affective condemnatory hyperbole often reigns with disrespect and censure for anyone interested in thinking beyond the limitations of the current labeling system.
Yes, it is undeniably true that scientific progress, as reported, does exist, is quite exciting, and does indeed increase the remission numbers dramatically – but the tradition of unabashed speculation about brain causality without a shred of evidence is quite alive and well.
Using the Evidence
Street psychiatrists, and even academically oriented psychiatrists who use, for example, imaging evidence in their own national presentations, continue to overtly disdain useful brain conclusions as not significantly proven, even after more than 20 years of replicated review. Further, they regularly freshen their static, limited labels with insufficient inquiry after inarguable medical symptoms living in the material they have just presented.
We in psychiatry hold ourselves to a different, more categorical, more perfectionistic standard than medical folk who regularly use generalized biomarkers as clinical assessment tools.
It's obvious, even to the public, that the naysayers are uncomfortable with the very fact that they don't know how to use the new material themselves, so condemn others who have used such evidence productively with more precise patient care.
Most distressing is the increasing trend to diminished dialogue with colleagues typified by the disdain for pharmaceutical companies who have contributed so much useful science to evolved patient care. In that missing dialogue resides important aspects of the evolution of psychiatric/neuroscience practice and improved patient care.
When did it become the populist medical ethic to avoid interface with fresh research and new facts from any resource? Is the only education available from esteemed halls of knowledge and tenure?
Just when and how did academia decide that clinical inquiry and reports of research findings, indeed medical teaching should only arise in medical institutions, not at dinner? I have never seen a physician swayed by pens or dinner, and find after many years of dinner meetings that our colleagues who attend are serious, attentive and motivated to learn as well as question.
Feedback loops between colleagues is encouraged, not diminished – W. Edwards Deming would not approve of this increasingly vertical management system and the associated intrinsic denial. Are those of us working daily at the front simply sharecroppers living in the fantasy land of small ‘n' numbers from isolated academic mavens who often deal with only one aspect of a multifaceted problem?
Psychiatric Labels & Polemics Create More Stasis
Bear in mind that these remarks are not categorically condemnatory of the current operational diagnostic and treatment grid, as I am not recommending we throw out a system that often does work well. To have a problem with some limitations of one process does not imply that the entire process requires replacement – we already suffer enough with polemics and reductionistic thinking.
Just as neurophysiologic inquiry attends many new variables, new language and new territories; it also suggests new methods of professional conduct. These few process improvements would help:
1. I suggest that we evolve our inquiry ethic by practicing more balanced discussion with less emotional dysregulation. Remember Freud threw out the cathartic theory before 1900. Further, affect dysregulation is unbecoming, counterproductive, and disrespectful.
2. Specific CME credits should accrue to those investing in more specific training for evidence-based interventions.
3. The DSM 6 should include biologically available grids that match with office symptoms and evidence.
4. The broader range of precise immune system inquiry, hormone dysregulation and neurotransmitter assessment associated with chronic illness needs our collective increased attention and reportage.
Let's move forward –
As always, I would be interested in your thoughts about these remarks – please do drop a comment to weigh in on this conversation.
Dr Charles Parker
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