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Psychiatric Diagnosis And The DSM-5 Controversy

I’ve followed in bits and pieces — sometimes for Shrink Rap, sometimes because the issues fill my email inbox, sometimes because there’s no escape. Oh, and lots of the players have familiar names.

In the December 27th issue of Wired magazine, Gary Greenberg writes a comprehensive article on the debates around the revision of the American Psychiatric Association’s (APA) upcoming revision of the Diagnostic and Statistical Manual (DSM) entitled “Inside the Battle to Define Mental Illness.” Do read it. Here’s an excerpt:

I recently asked a former president of the APA how he used the DSM in his daily work. He told me his secretary had just asked him for a diagnosis on a patient he’d been seeing for a couple of months so that she could bill the insurance company. “I hadn’t really formulated it,” he told me. He consulted the DSM-IV and concluded that the patient had obsessive-compulsive disorder.

“Did it change the way you treated her?” I asked, noting that he’d worked with her for quite a while without naming what she had.


“So what would you say was the value of the diagnosis?”

“I got paid.” Read more »

*This blog post was originally published at Shrink Rap*

The Relative Unimportance Of Diagnosis In Psychiatry

Look, he came back! Guest blogger Mitchell Newmark, M.D., put on his armor and came to blog with us again.

The Relative Unimportance of Diagnosis In Psychiatry

As we will soon be witness to the emergence of DSM-V, the new rule book for psychiatric diagnosis, I am reminded of all the pitfalls of diagnosis in psychiatry. In other fields of medicine, diagnosis is based primarily on etiology, with objective findings, rather than on symptoms alone, as it is in psychiatry. When you go to your internist with stomach pain, there’s an endoscopy to look for ulcers, a sonogram to look for gall stones, a blood test to look for hepatitis. But in psychiatry, there is no CT scan to check for bipolar disorder, no blood test to assess if the patient has schizophrenia, no spinal tap to check for major depression.

For the psychiatric community at large, diagnosis is important for many reasons. It helps doctors sort out patients so that clinical trials can be conducted on similar groups of patients. It enhances communication among psychiatrists when behavioral, affective and cognitive symptoms can be categorized. But for the individual patient, it is less useful. Some patients fit nicely into DSM categories, and others don’t. There are many patients who have unique combinations of symptoms across several diagnostic criteria. This leads to assigning multiple diagnoses, and confusing the treatment picture. Read more »

*This blog post was originally published at Shrink Rap*

Brain Damage, Behavior, And Football

In psychiatry, we’ve had a hard time drawing precise links between brain pathology and psychiatric disorders. We can do it for groups of people: “Disease X” is associated with changes in brain structure of “Brain Area Y” or metabolic changes in “Brain Area Z.” But it’s groups, not individuals, and it’s an association, not a cause-and-effect, or a definite. We still can’t use this information for diagnosis, and there are still patients with any given psychiatric diagnoses who will have brains where “Area Y” is the same size as those without the disorder. We’re learning.

From what I read in this New York Times article, Owen Thomas was a bright, talented young man with no history of psychiatric disorder and no history of known concussion. In April, he committed suicide — a tragedy beyond words.

Sometime people commit suicide and everyone is left to wonder: There was no depression, no obvious precipitant, no note left behind, and every one is left to wonder why. The guilt toll on the survivors is enormous, as is the grief for their families and communities. In this case, according to the Philadelphia Inquirer, the young man was apparently struggling with the stress of difficult school work and concerns about his team and employment.

Owen’s family donated his brain to Boston University’s Center for the Study of Traumatic Encephalopathy. They discovered that Owen’s brain showed damage similar to that seen in older NFL players — he had a condition called chronic traumatic encephalopathy. Read more »

*This blog post was originally published at Shrink Rap*

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