Saturday, June 29, 2013

To the Left and the Right of Dr. Frances

Allen Frances continues to erect his wall of criticism of DSM-5.  He shows no sign of slowing down even after the DSM-5 was released.  He has written a list of 18 problems in the Psychiatric Times that he characterizes as "glaring mistakes in wording and coding."  He believes that there were "egregious mistakes on almost every page I read."  That is a curious counterpoint to the opinion I heard recently from Jon Grant, MD when he presented the history, process, and details of the development of DSM-5. While Dr. Frances has undeniable DSM-IV experience there is always plenty of room for disagreement.  He comments that he has limited time for a detailed read of DSM and I have even less, so I will concentrate on 2 of his 18 points to illustrate what I mean.

Intermittent Explosive Disorder - Dr. Frances main complaint about this diagnosis is that is "lacks the needed exclusions to exclude the other more common causes of violent behavior."   The diagnostic criteria actually contains the exclusion:

F.  The recurrent aggressive outbursts are not better explained by another mental disorder.....and are not attributable to another medical condition.....or to the physiological effects of a substance.

Specific examples are given and there is also an exclusion for adjustment disorders in children.  The actual number of exclusionary diagnoses listed are essentially the same as DSM-IV and the discussion in the differential diagnosis is more extensive (p 612-613).  My problem is that I don't think this diagnosis actually exists.  That statement comes from over two decades of experience in acute care inpatient psychiatry, community psychiatry, and hospital psychiatry.  These are all settings on the front lines of aggressive behavior.  When the police encounter aggression and there is any question of an intoxication, medical problem, or mental disorder associated with that behavior - those people are brought in to settings where acute care psychiatrists are  involved.  In my experience of assessing extreme aggression up to and including homicide I have never seen a single case where the outbursts were not better explained by another mental disorder.  I don't agree that the exclusion criteria are any different.  I don't believe that this disorder exists.  If it does, the prevalence is so low that this acute care psychiatrist has not seen it in thousands of evaluations of aggressive behavior.

Mild Neurocognitive Disorder - Dr. Frances complaint about this diagnosis is "so impossibly vague that it includes me, my wife and most of our friends.  It will cause unnecessary worry and a rush to useless and expensive testing."

As I read through these criteria I have a much different perspective.  For about 10 years I ran a Geriatric Psychiatry and Memory Disorders Clinic where we did comprehensive assessments of patients with cognitive problems.  I worked with a nurse who would collect detailed information on patient's functional and cognitive capacity before they came into the clinic for my assessment.   A significant number of those patients had a strictly subjective complaint about their memory or cognition.      A large percentage of these patients did not have any insight into the severity of their problem and their typical assessment was: "My memory is no different than any other 60 or 70 year old."  Even though we had generally spent about three hours of assessment time with each patient, at the end of my evaluation we often did not have a clear diagnosis.  We would stick with that person until we did and often times the outcomes were surprising.  We had striking examples of chronic delirious states where the patient was given a diagnosis of dementia based on on neuropsychological testing, and with treatment and reassurance we observed their cognition to clear completely and they were restored to normal cognitive function.

I see the diagnosis of Mild Neurocognitive Disorder as a portal to that level of care.  Based on the list of 10 brain diseases and other medical conditions listed as specifiers the authors of this criteria clearly had that intent.  It is clear to me that any clinic with a high standard of care for patients with cognitive disorders like my clinic had can use this diagnosis both as part of the continuum to more Major Neurocognitive Disorders associated with progressive neurodegenerative dementias and to provide high quality assessments for patients with concerns about any cognitive changes.  Keep in mind that the typical managed care model would use a crude screening test and possibly refer for other psychological testing.  There might not be a physician in the loop who can make the necessary assessments and diagnoses.  Current research in this area also points to the need to identify patients as early as possible, especially as treatments become available.

On these two points I guess I am to the right of Dr. Frances on Intermittent Explosive Disorder and to the left on Mild Neurocognitive Disorder.  But I think the entire argument misses the mark if we think about the issue of psychiatric diagnosis and where the DSM fits in.  Any DSM cannot be used like a phone book to classify hundreds of different presentations to a Memory Disorder and Geriatric Psychiatry Clinic.  The unique conscious states of those individuals and their relative levels of impairment can only be determined by a comprehensive evaluation by a physician who is knowledgeable in all of the possible brain diseases that are suggested as etiologies.  Apart from the obvious increase in complexity for anything that is determined by a central nervous system, getting a diagnosis of Mild Neurocognitive Disorder is no different than getting a diagnosis of "Neck pain" or "Ankle pain" from a primary care physician.  And yes - those primary care diagnoses are very common.

The idea that there are precise criteria that can be written down and applied to make definitive diagnoses is a common misconception of the DSM and other diagnostic schemes.  To emphasize that point, I will end with a quote from Harold Merskey, FRCP, FRCPsych:

"Medical classification lacks the rigor either of the telephone directory or the periodic table."

That is all medical classification and not just the DSM-5.   A good starting point toward realizing the truth in this quote is to stop looking at the DSM-5 like it is a phone book.  You don't get a psychiatric diagnosis from the DSM-5.

You get a psychiatric diagnosis from a psychiatrist.

George Dawson, MD, DFAPA

Merskey H. The taxonomy of pain. Med Clin North Am. 2007 Jan;91(1):13-20, vii. PubMed PMID: 17164101

1 comment:

  1. Absolutely agree that intermittent explosive disorder does not exist, and that temper outbursts have causes. The problem is the "out of proportion to the stimulus" part, when the doctor would have to know the patient's whole life story, given honestly, to make that judgment. Same for DMDD or whatever it's called in kids. And lately, most doctors don't even take a minimal social history. So they know the outbursts are out of proportion to the stimulus how exactly?

    This is partly related to CBT folklore, where the stimulus and the behavior are always close in time - in animals! People, on the other hand, remember stuff for a long time. The Serbs and the Croats, and the Sunni and Shia Moslems, are still fighting over things that happened centuries ago.