Tuesday, June 18, 2013

DSM-5 and Primary Care

In the pre-DSM-5 hysteria, I posted the observation that primary care physicians were not "avid readers" of the DSM and therefore the idea that they would be likely to be influenced by it was erroneous.  Of course I was responding to the propaganda that the DSM-5 was basically a tool for psychiatric hegemony and that upstanding physicians everywhere would be mere pawns of organized psychiatry.  Tens of millions of people would be overmedicated.  There would be total chaos while Big Pharma, the APA, and psychiatrists everywhere lined their pockets with the proceeds of inappropriate prescribing.  In that atmosphere some considered my statement controversial.

From this week's American Medical News:

"....Perry A. Pugno, MD, MPH, vice president for education for the American Academy of Family Physicians, is not surprised that he hasn't heard about DSM-5 from the organization's members.

'From a pragmatic perspective, we don't use (the manual) very much,' he said. 'Most of the things we see we already know the diagnostic criteria for them.' " (page 12, AMEDNEWS, June 17, 2013).

Remember I also said that psychiatrists are not memorizing the DSM-5 either, for a similar reason.

As I think about what happened in the press before the release of DSM-5, mass hysteria is not a bad phrase.  Mass psychogenic illness is probably more politically correct these days but some experts consider an anxious form and a somatic form.  There are numerous examples of each and some references suggest that it is compounded by the presence of social media.  At any rate, the dynamic is very similar to the critical DSM-5 frenzy prior to the release.  In both cases, it can start as a rumor or speculative theory.  If that speculation sounds plausible to a larger group it is accepted and built upon.  At some point the response to the speculation is critical.  Will some experts step in and confirm the original speculation or introduce their own shocking hypotheses?  The reaction of the authorities takes it to the next level.  Will they seem to take the problem seriously. Media coverage makes things worse.  Will additional systems be activated to broaden the response?  Momentum builds and before you know it the anxiety or somatic symptoms are linked with a totally implausible hypothesis.  Some reviews suggest that treatment involves separating the affected individuals and keeping them out of the limelight for a while until the symptoms fade away.   As a psychiatrist who has treated many cases of conversion disorders with neurological symptoms using psychotherapy, I can't imagine competing with several "experts" in the media all having their own theories about the problem.  My guess is that my therapy would be either neutralized or severely protracted.

A lot of these things happened in the run up to the DSM-5.  So I am using mass hysteria here as a metaphor and not a "diagnosis".  I thought I should clarify that because I fully expect  that somebody would accuse me of that and go on to suggest that I am a control agent for somebody (?)

It is also not a diagnosis because it is not in DSM-5 or DSM-IV for that matter.

Hopefully cooler heads will prevail in the next big public controversy about psychiatry.  But I doubt it.

George Dawson, MD, DFAPA

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