Tira a La Basura El Dsm

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Dump the DSM !09-02-2006

Dump the DSM !Un point de vue décapant sur le DSM par un psychiatre américain. On en rierait plus facilement si l'on ne parlait de

nous l'imposer.Extraits :" - le DSM est une source inépuisable de moqueries pour nos collègues somaticiens,- il nécessite qu'on s'excuse en permanence envers les généralistes, les étudiants, les internes, et

occasionnellement les avocats et les juges,- la plupart de nos collègues cortiqués en rient sous cape,- il tient à des catégories rigides qui ne servent qu'à rendre confus et à désinformer les patients et leurs praticiens,

souvent influencés par le marketing du médicament,- il est si incohérent qu'il fait se lever les yeux au ciel des nos patients en psychothérapie pour peu qu'ils soient

instruits ou aient l'esprit critique,- il finit par convaincre tout le monde que la psychiatrie n'a rien d'intéressant à dire sur la condition humaine",L'article a dû toucher au but pour que Michael First, M.D., and Robert L. Spitzer estiment devoir y répondre (ici).

Source : http://www.psychiatrictimes.com/

Dump the DSM ! by Paul Genova, M.D. Psychiatric Times April 2003 Vol. XX Issue 4

(Please see Counterpoint article by Michael First, M.D., and Robert L. Spitzer, M.D.) The American

Psychiatric Association's DSM diagnostic system has outlived its usefulness by about two decades. It should beabandoned, not revised. Its primary achievement was to force American psychiatrists to recognize that not all patientspresenting with florid psychoses had schizophrenia. More generally, it aimed to force the idea of operationally definedsyndromes down the throat of a profession that was still, in the 1970s, dominated by the vague and archaic concepts ofpsychoanalysis at its American 1950s worst.

These goals have long since been accomplished, and, like the preceding analytic vagueness, it is time for thearbitrary, legalistic symptom checklists of the DSM to go. (The lag time would be about the same, 20 years or so.) Letme say at the outset that I do not wish to disparage all the hard and well-intentioned labors of the various work groupsthat developed the different sections of these books in their several editions or to deny the enormous amount ofinformation summarized therein. But again, the aggregate is an awkward, ponderous, off-putting beast that discreditsand diminishes psychiatry and the insight of those who practice it. Consider the fact that your clinical practice is

governed by a diagnostic system that: * is a laughingstock for the other medical specialties; * requirescontinual apologies to primary care doctors, medical students, residents, and the occasional lawyer or judge; *most of our thoughtful colleagues privately rail against;; * insists upon rigid categories that often serve only toconfuse and misinform patients and their clinical workers (sometimes abetted by televised drug advertising); * isso intellectually incoherent as to raise eyebrows among the well-educated, critical thinkers in our own psychotherapyclientele; * persuades the world at large that psychiatry no longer has anything of interest to say about the humancondition. If it were within your power to do so, wouldn't you get rid of this system? Let us make a tourof some of the diagnostic categories we all use and abuse. Schizoaffective disorder comes immediately to mind. Someargue that schizoaffective disorder should be a rare diagnosis. As unhappy as I am with the DSM-IV description, theyreach an opposite conclusion to my own. Rightly criticizing the arbitrariness of the current criteria for this disorder (twoweeks of hallucinations or delusions in the absence of prominent mood symptoms, but prominent mood symptoms for a"substantial portion" of the illness), one authority has even speculated that the confusion about schizoaffective disorderdeters medical students from entering psychiatry! I rather think that it is today's incarnation of the DSM, theDSM-IV, that deters medical students from entering psychiatry. Strict diagnostic criteria (which some want to repair bymaking them still stricter) reflect neither biological nor clinical reality. These realities simply will not yield to anyone'sdesire for precision. On the research front, recent studies suggest that there is considerable overlap in the geneticvulnerability for schizophrenia and for bipolar disorders. What is the point of false precision when the genes themselvesare imprecise? And when I make my weekly visit to the revolving-door world of Mental Health Clinicland, wherebrief med checks are the usual context for my best efforts, schizoaffective disorder is among the most commondiagnoses I make. One reason, of course, is that reliable histories of precisely defined symptom clusters and periods oftime are usually impossible to obtain, while many of my patients have both psychotic and mood disorder features mostof the time, fitting neither of the DSM-IV's clear bipolar or schizophrenic pictures. Another reason is that theclinical syndromes we treat, whatever their genetic underpinnings, are themselves changing. If the reader will permit abrief digression, the schizoaffective debate reminds me of debates over whether black lung disease was a real illnesswhen I was in general practice in East Kentucky years ago. Some physicians, particularly those hired by mining

companies' liability insurers, held that it was simply chronic obstructive pulmonary disease (COPD). Indeed, most of theminers who suffered from it were also smokers. But the fact was that black lung behaved differently than typical COPD.At least in my care, it seemed to have a restrictive, as well as an obstructive, nature and needed more and earliersteroid treatment. These men had spent their lives breathing coal dust. Today, our young bipolar patients arespending their lives ingesting antidepressants, cocaine, methamphetamine, methylenedioxymethamphetamine (MDMA)and hallucinogens over prolonged periods. These chemicals change their brains, just as coal dust changes lungs. Inter-

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episode recovery, a hallmark of classic bipolar disorder, becomes a thing of the past. Delusions, hallucinations andmood-cycling become entrenched, and antipsychotic maintenance essential. I could try to be strict and pile up two orthree Axis I diagnoses to describe this entity, thereby confusing everyone else involved in the patient's care. Instead,and with no apology, I call it schizoaffective disorder, which is more easily explained to nonpsychiatrists as anonhomogeneous in-between category. One can leaf through the DSM-IV and find countless howlers andparadoxes, as I am sure many readers have already done. More important are major problems like the relationship ofnarrowly defined posttraumatic stress disorder to the commonly found clinical entity of "chronic complex PTSD," whichincludes mood-cycling, dissociative and/or psychotic features, and predictable personality and boundary derangements.

Again, we need to pile up several Axis I and II labels to strictly diagnose--and obfuscate--a familiar clinical presentation.Aside from conversion disorder, the somatoform disorders are a mess (four pain symptoms, two gastrointestinalsymptoms and so on). Primary care physicians never use these diagnoses, instead sticking with the clinicalpresentations they see, such as fibromyalgia syndrome. Anxiety disorders are artificially separated from the mood andpsychotic disorders with which they are usually intertwined, yielding the frequent question, "If I have an anxiety disorder,why are you treating me with an antidepressant?" How many cases of pure generalized anxiety disorder have youseen? Of isolated social phobia? And so on. The personality disorders section, categorical as it is, has beenvery effective in stifling nascent psychodynamic thinking among our trainees. Many of these "disorders" are extremeforms of various dimensions of normal personality. Their very extremeness is often, indeed, state-dependent withregard to other psychiatric illness and general stress level. The truly dynamic aspects of some of the more interestingones, such as narcissistic and borderline personalities, have been bled out of the DSM categories. For example, a"deflated" aspect of narcissism, which presents with outward "low self-esteem" around a grandiose core, exists invariable equilibrium with the outwardly grandiose aspect described in DSM-IV, wherein it is nowhere to be found (see

my essay "The Endless Walk of the Fool" in The Thaw [The Analytic Press, 2002]). And although observing how thesecharacter-disordered patients respond in treatment is the sine qua non of psychodynamic diagnosis, fundamentaldescriptions of such responses, such as the discussions of borderline personality organization by Otto Kernberg, M.D.,are omitted. In fact, psychiatrists who specialize in any one of the major subject areas in the DSM-IV seemalmost universally frustrated by "their" section of the book. This is equally true of analysts specializing in personalitydisorders, clinical researchers in major mental illness, traumatologists and neurobiological investigators. Overlappingdimensions, or spectra, of pathology much more accurately reflect clinical reality, whether we are talking about thenarcissistic/borderline personality spectrum or the bipolar, schizophrenia, obsessive-compulsive or autistic spectra.When they can, biologically oriented researchers come up with their own criteria (like the negative/positive symptomclusters in schizophrenia), while psychodynamic and cognitive-behavioral writers put forward alternative ways to look atpersonality function in therapy settings. The DSM-IV's relationship to all this is as a Berlitz phrase book is to the Towerof Babel. And then there are those horrible Axes. I suppose they were designed with good intentions. Theymade us think always of the medical picture (Axis III) and originally tried to save a place for psychodynamics (Axis II).

Today, we all know to think of the medical situation, and the Axis I=biology/Axis II=psychology distinction is blurred:patients with schizotypy have the eye-tracking abnormalities of schizophrenia, people with chronic PTSD often haveborderline psychodynamics. The Global Assessment of Function (Axis V) is good for generating the followingquip: "Subtract 20 if you want to get the treatment plan approved!" And Axis IV, "psychosocial problems," shows noappreciation of the varying symbolic import of life events. These subjective judgments are not part of a diagnosis. Theybelong in a good narrative note with specific examples and a little originality in the use of adjectives! Granted,there are disclaimers in the current manual's introduction about not taking categories literally and not regarding DSMdiagnoses as a complete understanding of the patient. But these muted caveats do not help to reverse the fact that theDSM, by its very existence in its present form, implicitly encourages the entire mental health care system to do thosevery things. It is a tacit endorsement of false precision and superficial literalism in psychiatric assessment. Twoquestions arise from this situation, and the first is, Why? Why maintain and elaborate a diagnostic system that no one ishappy with? A skeptic need look no further than the catalogues full of DSM-IV treatment guides and companions, DSM-IV-keyed textbook editions, DSM-IV software and the like that fill every psychiatrist's mailbox. The DSM-IV is a big

moneymaker for the APA. Who dares practice--indeed who can practice--without the reigning bible close at hand? Imaintain that the APA is holding back the development of the profession it represents by maintaining its income and itsinstitutional hegemony over American mental health care with the DSM system. A final question is: What do Isuggest instead? My regular readers well know that I am better at tearing down than at building, but I will try.Researchers, of course, will always need research diagnostic criteria and are good at coming up with them. Thesesame researchers ought to also pay some attention to operationalizing and studying the real, dirty categories that realclinicians use. This is already happening to some extent, as the pitfalls of excluding most of the patients we treat fromresearch studies have become apparent. The IDC-9 or ICD-10 would provide a perfectly good alternative forbilling and coding purposes, and perhaps the APA could let the World Health Organization take back the job ofdeveloping future code bibles, rather than duplicating the task. While we will always need an administrative diagnosticsystem, the APA's resources are better spent finding ways to get people excited about--and interested in--the rich scopeof the field it represents, instead of endlessly rehashing an arid and intimidating set of menus. As clinicalpsychiatrists communicating among ourselves and to other specialties and concerned parties, we need not takediagnostic categories literally. We can save the major valid diagnostic syndromes like paranoid schizophrenia, or panicdisorder with agoraphobia, but append other features freely and, most important, change our basic diagnostic stance toa dimensional rather than a categorical one. Arbitrary checklists and time cutoffs ("more than two weeks," "less than sixmonths") can be dispensed with in favor of our best global diagnostic impressions. The focus of psychiatric treatmentshould be a single diagnosis--a single person--in most cases, with no tiresome Axes involved. Impressions of





personality contributions, "stressors" (how I hate the word--its generic tone invites us to leave the patient's story out!),relevant medical illness and so on can go back into a narrative note to be discussed in a nuanced way. Attempts toquantify functioning can be confined to research and otherwise left to lawyers, government agencies, insurancecompanies and the psychiatrists they employ. Will this ever happen? As my French-Canadian grandmotherused to say, "Don't hold your breath!" (Interested readers are advised to go to the Web site by Paul McHugh,M.D., [www.hopkinsmedicine.org/jhhpsychiatry/perspec1.htm] and read his systematic and cogent 1992 discussion ofthese same issues. From his lofty position as chair of psychiatry at Johns Hopkins University, he has long advocated forchange in our diagnostic system.) Dr. Genova, a clinical associate professor of psychiatry at the University of

Vermont, has practiced in Maine for 21 years and is author of The Thaw: Reclaiming the Person for Psychiatry (TheAnalytic Press, 2002).



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