Psychiatric Diagnosis and DSM 5: Maps to Nowhere

by Dr Charles Parker on February 13, 2010 · 26 comments

Diagnostic Bible: Scientific Heresy

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

You may be thinking 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 rules, measuring thinking is still out.

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

The DSM5 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See this brief description in the LA Times and you will catch the drift and controversy on these new, already outdated diagnostic maps. Our books are outdated simply because we aren’t learning how to read the brain images and the lab reports.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

New Criteria for Psychiatric Diagnoses Proposed (blogs.sciencemag.org)
Mental Health ‘Bible’ Starts Revamp With New Terminology, Diagnoses (medicalnewstoday.com)
UCLA Psychiatrist Criticizes DSM-5 (furiousseasons.com)
DSM-V: Suggestions for Change (psychcentral.com)
Demystifying Psychiatry: An Interview with Charles Zorumski and Eugene Rubin (psychcentral.com)

Psychiatric Diagnosis and DSM 5: Maps to Nowhere

Digitally available now at Nook, Kindle, Barnes and Noble.
ADHD Medication Rules – PDF For Your Desktop
ADHD Medication Rules | Paying Attention To The Meds For Paying Attention – Kindle Version

Tagged as: ADD Medications, ADHD, Attention-deficit hyperactivity disorder, biomarkers, Bipolar Disorder, brain function, Depression, diagnostic manual, Dr Charles Parker, DSM 5, Gluten sensitivity, Health, Health care, Medicine, Mental disorder, Mental health, Neurotransmitters, psychiatric diagnosis, Psychiatric evidence, Psychiatric Medications, Psychiatry, SPECT, Stimulant medications

Welcome back. Recent articles you might of have missed

You may want to subscribe to my RSS Feed. Thanks for visiting!

Pingback: News Round-Up 2010 « The Amazing World of Psychiatry: A Psychiatry Blo
Pingback: New Book – The Patient’s Guide for ADHD Medication Rules by Dr. Charles Parker | ADDER WORLD ADD ADHD Positive Thinking
http://adventurestudio.com Kate

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!!

http://www.CorePsychBlog.com Dr Charles Parker

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
Denise

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

Pingback: Review: The DSM-5 debate « Psych Maven
Pingback: News Round-Up: February 2009 3rd Edition « The Amazing World of Psychiatry: A Psychiatry Blog
Pingback: DSM 5 Diagnosis: Psychiatric Institution Lockdown
http://www.TheUnstickingCoach.com Lyle T. Lachmuth – The Unsticking Coach

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

http://www.CorePsychBlog.com Dr Charles Parker

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

http://addmsorboth.blogspot.com/ Scott Hutson

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

http://www.CorePsychBlog.com Dr Charles Parker

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

http://addmsorboth.blogspot.com/ Scott Hutson

Thats why I’m here, Dr. Parker. Thanks again, I’m looking foward to it! Any info, good news or bad, is good news for me in my search!..Scott

http://www.CorePsychBlog.com Dr Charles Parker

Scott,
That attitude will get the job done, for sure.
cp

Betsy Davenport, PhD

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.

http://www.CorePsychBlog.com Dr Charles Parker

Betsy,
Thanks for weighing in so eloquently – great to hear your take from an esteemed member of the mental health community!
cp
http://www.ADHDRollerCoaster.com Gina Pera

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

http://www.CorePsychBlog.com Dr Charles Parker

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

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.

http://www.CorePsychBlog.com Dr Charles Parker

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

http://www.ADHDRollerCoaster.com Gina Pera

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.

http://www.CorePsychBlog.com Dr Charles Parker

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

http://www.ADHDRollerCoaster.com Gina Pera

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.

http://www.CorePsychBlog.com Dr Charles Parker

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
Betsy Davenport, PhD

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.

http://www.CorePsychBlog.com Dr Charles Parker

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