DSM-5.0

I finally saw a copy of the DSM-5 today.  It was sitting on a table at a course on the DSM put on by the Minnesota Psychiatric Society.  The DSM-5 portion of the course was about 3 1/4 hours of lectures (98 information dense PowerPoint slides) by Jon Grant, MD.    Dr. Grant explained that he was in a unique position to provide the information because he and Donald Black, MD had been asked by the American Psychiatric Association (APA) to write the DSM-5 Guidebook.  In this unique position they were privy to all of the notes, minutes, e-mails and documents of the DSM Work Groups.  In the intro it was noted that Dr. Grant had written over 150 papers and 5 books.  He was probably one of the best lecturers I have ever seen with a knack to keep the audience engaged in some very dry material.  There were times that he seemed to be riffing like a stand up comedian.  The content was equally good.  I thought I would summarize a few of the high points that I think are relevant to this blog.

The first section was an overview of the history.  The original DSM was published in 1952, but before that there were several efforts to classify mental disorders dating back to ancient times.  Some of the systems persisted for hundreds of years.  He credited Jean-Etienne Esquirol (1772-1840) as one of the innovators of modern classification.  The philosophical approaches to the subsequent DSMs were reviewed and they generally correlate with the theories of the day.

The development of DSM-5 began in 1999.  The original goals included the definition of mental illness, dimensional criteria, addressing mental illness across the lifespan, and to possibly address how mental disorders were affected by various contexts such as sex and culture.  Darrel Regier, MD was recruited from the NIMH to coordinate the development of DSM-5 in the year 2000.  Between 2003 and 2008 there were 13 international conferences where the researchers wrote about specific diagnostic issues and developed a research agenda.  This produced over 100 scientific papers that were compiled for use as reference volumes.  As far as I can tell the people on the ground on this issue was the DSM Task Force and the Work Groups.  The Task Force addressed conceptual issues like spectrum disorders, the interface with general medicine, functional impairment, measurement and assessment, gender and culture and developmental issues.  The Work Groups met weekly or in some cases twice a week by conference call and twice a year in person.  The work groups had several goals including revising the diagnostic criteria according to a  review of the research, expert consensus and "targeted research analyses".  No cost estimate of this multi-year infrastructure was given.

Like any volume of this nature the originators had some guiding principles including a focus on utility to clinicians, maintaining historical continuity with previous editions, and the changes needed to be guided by the research evidence. The most interesting political aspect of this process was the elimination of people closely involved in the development of DSM-IV in order to encourage "out of the box" thinking.  This was a conscious decision and I have not seen it disclosed by some of the professional critics out there.

Final approval of the DSM occurred after feedback was received through the DSM-5 web site.  There were thousands of comments from individuals, clinicians and advocacy organizations.  Field trial data was analyzed and discussed.  A scientific committee reviewed the actual data behind the diagnostic revisions and confirmed it.  Hundreds of expert reviewers considered the risks in revising the diagnoses.  The APA Assembly voted to approve in November 2012.

Some of the criticisms of the DSM-5 were discussed in about 4 slides.  Dr. Grant was aware of all of the major criticisms and I have reviewed most of them here on this blog such as the issue of diagnostic proliferation.  Dr. Grant's lecture contained this graphic for comparison:

Rather than repeat what I have already said, it should be apparent to anyone who knows about this process that it was open, transparent and involved a massive effort of the part of the psychiatrists and psychologists involved.  It should also be apparent that the DSM process was clinically focused and that safeguards were in place to consider the risk of diagnostic changes.  I have not seen any of that discussed in the press and don't expect it to be.  For all of you DSM-5 conspiracy theorists, more than enough people involved without a sworn oath to assure that no secret would ever be kept.

What about the final product?  The DSM-5 ends up including 19 major diagnostic classes.  Some of the highlights include moving some disorders around.  Obsessive-compulsive disorder and Post Traumatic Stress Disorder were moved out of the Anxiety Disorders section to their own separate categories.  Bipolar and Depressive Disorders each have their own diagnostic class instead of both being placed in a Mood Disorders class.  Adjustment Disorders have been moved into the Trauma and Stress Related Disorders class and there are two new subtypes.  As previously noted here, all of the Schizophrenia subtypes have been eliminated.  The Multiaxial System of diagnosis has been scrapped.  One of the changes impacting the practice of addiction psychiatry is the elimination of the categories of Substance Abuse and Substance Dependence and collapsing them into a Substance Use Disorder.  Panic attacks can now be used as a symptom of another disorder without having to specify that the person has panic disorder and that is a pattern I have observed over the course of my career.  The controversial Personality Disorders section is unchanged but there is a hybrid diagnostic system that includes dimensional symptoms, the details of which (I think) are in the Appendix.  Mapped onto all of the diagnostic classification and criteria changes are a number of subtypes and specifiers as well as a number of ways to specify diagnostic certainty.  As with previous editions since DSM-III there is a mental disorder definition that indicates that behavior or criteria are not enough.  There must be functional impairment or distress.  The definition specifies that socially deviant behavior or conflicts between the individual and society do not constitute a mental illness unless that was the actual source of the conflict.

The overall impression at the end of these lectures was that this was a massive 18 year effort by the APA and hundreds and possibly thousands of volunteer psychiatrists and psychologists.  None of those volunteers has a financial stake in the final product.  Many of the criticisms were addressed in the process and many of the critics have a financial stake in the DSM-5 criticism industry.  The criticisms of the DSM-5 seem trivial compared with the process and built in safeguards.  The DSM-5 was also designed to be updated online instead of waiting for another massive effort to start to make modifications, hence this is not DSM-5 but DSM-5.0.

If Dr. Grant is lecturing in your area and you are a psychiatrist or a psychiatrist in training, these lectures are well worth attending.  If you have a chance to look at his Guidebook, I think that it will be a very interesting read.

George Dawson, MD, DFAPA

Supplementary 1:  The DSM-5 Guidebook by Donald W. Black, MD and Jon E. Grant, MD came out in March 2014.  Table 1.  (p.  xxiii) lists the total diagnoses is DSM-5 as 157 excluding "other specified and unspecified disorders". 

A Valentine from the President

I caught the link to this fact sheet from President Obama a couple of days ago on the APA's Facebook feed.  In the post immediately before it, the current President of the APA is seen rubbing elbows with Bradley Cooper.  My first thought is that these initiatives are always a mile wide and an inch deep.  They provide a lot of cover for politicians who have enacted some of the worst possible mental health policy, but also for professional organizations who have really not done much to change mental health policy in this country.  These are basically non-events as in we applaud the President and he applauds us.  In the meantime, patients and psychiatrists are never given enough resources for the job and the necessary social resources keep drying up.

Since the 1970s, the political climate in the US has focused on being as pro-business as possible.  Congress practically invented the credit reporting industry and in turn that industry made it easy for businesses to change your fees based on a credit report number.  What you have to pay for home and auto insurance can be based solely on your credit rating and independent of whether or not you have ever missed a payment.  It turns out that competitiveness is little more than political hyperbole.  But the politicians in Washington did not stop there.  The financial services industry is currently a multi-trillion dollar enterprise with little regulation or oversight that has essentially placed all Americans at financial risk.  There is no better proof than the fact that there are currently no safe investments and that some advisors are suggesting that prospective retirees need as least $1 million dollars in savings and $240,000 for medical expenses in addition to whatever is available in Medicare and Social Security.   Congress's retirement invention the 401K has surprisingly few accounts with that kind of money.

How can a government that puts all of its citizens at financial risk all of the time manage the health care of those same citizens?  It is a loaded question and the answer is it cannot.  The idea that an administration has an initiative to "increase understanding and awareness of mental illness"  at this point in time is mind numbing in many ways.  We  have had over two decades of National Depression Screening Day, we have Mental Illness Awareness Week, and we have had the Decade of the Brain.  There seem to be endless awareness initiatives.  I don't think the problem with mental health care is the lack of awareness or screening initiatives.  From what you can see posted on this blog so far, it might be interesting and productive to have some media awareness events that look at the issue of media bias against psychiatry and the provision of psychiatric services.  I don't think it is possible to destigmatize mental illness, when the providers of mental health care are constantly stigmatized.

What about the issue of screening at either a national level or at the level of a health plan?  A fairly recent analysis commented that there have been no clinical trials to show that patients who have been screened have better outcomes than those who are not.  Further, that weak treatment effects, false positive screenings, current rates of treatment and poor quality of treatment may contribute to the lack of a positive effect of the screening.  The authors also refer to a study that suggests that more consistent treatment to reduce symptoms and reduce relapse would lead to a greater treatment effect than screening.  A subsequent guideline by the Canadian Task Force on Preventive Health Care agreed and recommended no depression screening for adults at average or increased risk in primary care setting, based on the lack of evidence that screening is effective.  Why in the President's fact sheet are the AMA and APA recommending screening?  Why are there people advocating for "measurement based care" and the widespread use of rating scales and screening instruments?  Why does the State of Minnesota demand that anyone treating depression in the state send them PHQ-9 scores of all of the patient they treat?

The answer to that is the same reason we have political events that add no resources to the problem and make it seem like something is happening.  Screening everywhere makes it seem like somebody is concerned about assessing and treating your depression.   It makes it seem like we are destigmatizing mental illness and making diagnosis and treatment widely available.  The Canadian papers noted above suggest otherwise.  Nothing is happening, except people are being put on antidepressants at a faster rate than at any time in history.  In a primary care clinic, medications are the first line treatment and psychotherapies - even psychotherapies that are potentially much more cost effective than medications are rarely offered.

My professional organization here - the APA has chosen to advocate for an "integrated care" model that is managed care friendly.  A model like this can use checklist screening and essentially have consulting psychiatrists suggesting medication changes on patients who do not respond to the first medication.  I obviously do not agree with that position.  Only a grassroots change here will make a difference.

If you are concerned that you might have significant depression, you can't depend on your health plan or the government when they are both advocating for a screening procedure that has no demonstrated positive effect.  If somebody hands you a screening form for depression or anxiety or sleep or any other mental health symptom, tell them that you want  to be interviewed and diagnosed by an expert.  Tell them that you want the same approach used if you come to a clinic with a heart problem.  Nobody is going to hand you a screening form that you can complete in 2 minutes.  You are going to see a doctor.  Tell them that you want that expert to discuss the differential diagnoses, the likely diagnoses and the medical and non-medical approaches to treatment including counseling or psychotherapy.

Do not accept a cosmetic or public relations approach to your mental health and spread that word.

George Dawson, MD. DFAPA

Two Undergrad Experiments to Illustrate - What Is Science?

I have always been somewhat of a science nerd and had what I consider to be a first rate science education at a liberal arts college.  I had gone to this school on a football scholarship with the intention of becoming a phy ed teacher and a football coach, but the science education there was too compelling to ignore.  I ended up being a biology and chemistry major and rapidly forgot about football.  Brook's essay of what is science, what is the most compelling science and how that  makes psychiatry as far from science as possible led me to think about memorable experiments from my undergrad days.

Experiment 1:  The Limnology experiment:   For a while in my undergrad career, I considered being a limnologist or fresh water biologist.  My undergrad college was one of the first to emphasize the environment and ecology.  A lot of the work involved doing population estimates of plankton and aquatic invertebrates.  We spent hours classifying and counting thousands of organisms  that are unknown to most people. We used various sampling techniques and statistics to determine populations of these organisms and whether they seemed to be influenced by any environmental variables.  At one point I had equations from an journal article to calculate the probability that a specific species would be in contact with another one - called the "probability of inter species interaction."  This is biological science.

Experiment 2:  The PChem experiment:  Physical Chemistry was the undergrad chemist's dream course when I was in college.  You dreamed that you would be able to pass it.  We had a text that was not very accessible, but a professor who was brilliant, very accessible and an excellent lecturer.  I liked it a lot after we finished thermodynamics and moved on to other topics.  Back in the 1970s we had very primitive computing power. Our lab had an old HP calculator that was as big as a current desktop with less computing power than a modern day scientific calculator.  One of our tasks was to estimate electron densities around carbon atoms in aromatic hydrocarbons.  In an afternoon in the lab we ran the numbers.  This was the science of physical chemistry.

I have intentionally left out all of the details of the experiments because for the purpose of comparison with Brooks thesis they are unnecessary.  From his essay we learn that biology and chemistry are real sciences with a "distinctive model of credibility".  The examples I have given are from those fields.   We learn that psychiatry is a "semi-science" because "the underlying reality they describe is just not as regularized as the underlying reality of say, a solar system".  I will stop at that point because Brooks further examples rapidly degenerate.  What do we have so far?

Looking at my experiments, #2 clearly has the regularity of a solar system.  What could be more regular than the electron density for a specific molecule?  It fits Brooks definition of science to a tee.  What about experiment #1, the biological experiment?  Here we have a number of organisms.  Some have nervous systems and the others (eg. phytoplankton) do not.  I did a series of calculations to look at the probability of one species encountering another.  There were certain assumptions to those calculations about randomness to make the calculation much easier to do.  But what if I wanted for a moment to be a "behavioral limnologist" and attempt to predict the behavior of a specific stoneflies in the sample?  What if I wanted to determine the 5%  of stoneflies that exhibited behavioral characteristics, that differentiated them from the other 95%?  Suddenly we have a problem.  The source of that problem is a nervous system.  The underlying reality of most even slightly complicated nervous systems is that they will never have the regularity of a physical system.  They have evolved not to.  Regularity in a nervous system locking it into a physically predictable system is not in any way adaptive for any animal that needs to forage and reproduce.  It is the kiss of death.

But is gets complicated at additional levels.  The human brain is highly evolved to have significant processing power.  At another level, there are theoretical concerns about whether it is possible to ever to map behaviors and psychiatric symptoms directly onto some neurobiological system.  Unlike my experiment 1 above we are rarely interested in looking at only life or death as the outcome variable.  The variables that will allow us to study different populations are going to be much more complex than grossly observed behaviors.  There is a complicated nervous system between those behaviors and the environment.

Is psychiatry really not a science because it is complex and attempts to deal with the complicated phenomena associated with the human brain?   Should we ever be concerned about 1:1 mappings of psychiatric disorders onto a specific genetic or neurobiological defect?  Is it possible that a human nervous system is so complex that it is unrealistic to expect that this might happen?

Unlike Brook's theme nobody is a "Hero of Uncertainty".  Uncertainty is the expected condition and one that every psychiatrist should be comfortable with.  Psychiatry and the associated neurosciences will never be reduced to the predictable calculation of a physical system and that has nothing to do with one being a more prestigious science.  It has to do with evolution and complexity.  It has to do with what philosophers call the "demarcation problem" between what is and what is not science.  More to come on that in the near future.

George Dawson, MD, DFAPA

Brooks on Psychiatrists As "Heroes of Uncertainty"

Well I suppose it is slightly better than the usual characterizations that we see in the New York Times, but David Brooks recent column on the "improvisation, knowledge and artistry" involved in psychiatry is little more than damning with faint praise.  His flaws include using the term "technical expertise" and comparing psychiatry to "physics and biology".  Psychiatry is certainly comparable to biology but not to physics.   And what is it about psychiatry that is unscientific?  The idea that psychiatry seeks to legitimize itself by appearing to be scientific is a popular antipsychiatry theme.  It is probably why many authors seek to equate psychiatry with the DSM.  The science of psychiatry is out there in many technical journals that are scarcely ever mentioned in the public commentary about psychiatry.  The idea that the science of psychiatry is collapsed into a modest (at best) diagnostic manual is a convenient way to deny that fact and portray psychiatrists as unscientific and perhaps not very much like physicians either.  

Brooks characterization of the DSM shows a continued lack of understanding of this manual by  every journalist who writes about it.  There is practically no psychiatrist I know of who considers it to be authoritative.  Very few psychiatrists  actually go about their diagnostic business by reading through DSM criteria.  That activity would be limited to novices and medical students.    It is well known that only a fraction of the diagnoses listed are ever used in clinical practice.  After familiarizing themselves with the major changes, few psychiatrists will every open it again.   Like most physicians, psychiatrists are looking for patterns of illness that are based more on their clinical experience than criteria listed in a manual.  The idea that this text has "an impressive aura of scientific authority" is certainly consistent with Brook's thesis, but that is not what a psychiatrist experiences when looking at it.  Despite all of the concern about the public impact - psychiatrists are the target audience here.  Psychiatrists are much more aware of the limitations of the approach than the media critics who write about it.  I guess a lay person might be impressed, but I never met a psychiatrist who was.  

Brooks is also confused about the nature of the DSM when he states that it contains "a vast body of technical knowledge that will allow her (your psychiatrist) to solve your problems".  That vast body of technical knowledge is firmly outside of the DSM and it is in the form of training and ongoing education of a psychiatrist.   That technical knowledge is contained in a vast literature, much of it written by psychiatrists.  It is the reason that ongoing training and education of physicians is a career long commitment.  In the general scope of things, the DSM would contribute a percentage point or two at most to that body of knowledge.

There is the associated question about whether physicians are scientists or not.  I have seen Kandel himself interviewed about this issue and he states quite definitely that they are not.  That is quite different from suggesting that physicians are unscientific.  There are certainly not many physicians who are performing scientific experiments and publishing papers.  I suppose that you have to do that to be a professional scientist.  On the other hand, physicians are certainly accountable for learning immense amounts of of scientific principles and data that can be applied in clinical situations and used in critical thinking about patients and teaching it to successive generations of physicians..  I teach Dr. Kandel's plasticity concept and how it applies to addictions in about 30 lectures a year.  Reducing scientific knowledge to "artistry" is really inconsistent with "technical expertise".  There really is no art in medicine.  The most technically competent doctors know the science, have seen more patterns of illness and can recognize those patterns.  They can apply that knowledge to patient care.  In complex medical (and psychiatric) care, a special plan can be designed for each individual patient and most aspects of that plan are rooted in science.

This essay strains under the weight of needing to place psychiatry outside of the scope of science and mainstream medicine.  My study of psychiatry finds it in neither of those locations.  There is a reason that psychiatrists need to go to medical school.  The cross section of basic science and clinical science that all physicians are exposed to is necessary to be a psychiatrist.  Using Brooks reasoning, I suppose he could say that this is just an effort to "legitimize" psychiatry by making it seem like it is on scientific par with the other fields of medicine.   When I am face to face with a severely ill patient who has liver disease, heart disease, diabetes, alcoholism and a refractory psychiatric disorder - the science involved is much more than a political exercise.   

Like every other branch of medicine, psychiatry is an amalgam of the clinical and basic sciences.  Biology especially neuroscience but also the anatomy and physiology of the human body is the central focus.  I will give Brooks partial credit when he writes about the DSM.  Unlike many of his colleagues at the NY Times - he does not refer to it as a "Bible".  When it comes to the issue of whether I am a scientist or not, I certainly realize that I am no Eric Kandel.   But I also know that I am not rolling the dice or taking a leap of faith.   I am  doctor seeing people, trying to understand their unique set of problems, and applying medical science to help them get better.

George Dawson, MD. DFAPA

David Brooks.  Heroes of Uncertainty.  NYTimes May 27, 2013.

Suggested Changes to Psychiatric Residency Programs

I received an e-mail two weeks ago that asked for my suggestions on immediately reforming residency programs for psychiatry.  I had the experience of completing my residency in two different university based programs.  My residency occurred at the height of the controversy between the self described biological psychiatrists and the psychotherapists and psychoanalysts.  Although I have never seen it written about there was open animosity between the groups at times.  A biological psychiatrist back in the day might make a statement like: "I don't do talk therapy".  A psychotherapy oriented psychiatrist might refer to the biological types as "Dial twisters" referring to an approach that suggested excessive biological reductionism.  Apparently neither group had read Kandel's seminal article in the New England Journal of Medicine four years earlier and how plasticity can be affected by talking, medications, and of course other experiences.

Several years ago, I attended an anniversary of the University of Wisconsin Department of Psychiatry, the program I eventually completed my residency at.  Thomas Insel, MD was one of the invited speakers.   He outlined a revolutionary approach to educating psychiatry residents that involved a joint 2 year neuroscience internship with residents from neurology and neurosurgery.  He did not provide any details.  When I sent him a follow up e-mail two years later, he said it would probably not happen on his watch.  I can easily build on that theme.  I think that a two year program focused on basic and clinical neuroscience remains a good approach.  The current approach to getting the relevant information is haphazard at best.  It depends on lectures in neuroscience being interspersed with clinical rotations of varying quality and to a large extent it depends on the faculty.  How many faculty are there and how many of them are expected to produce managed care style billings or "productivity" rather than high quality teaching.

A comprehensive and integrated approach that will teach state of the art neuroscience and provide the relevant training in neurology and medicine is possible.  There are many obvious areas for improvement.  Residents often spend their time on clinical rotations of minimal relevance for psychiatrists.  I can recall learning ICU medicine and needing to familiarize myself with various tasks (Swan-Ganz catheters, central lines, ventilator settings, dopamine drips, balloon pumps) that I would never use again.  I needed to be seeing hundreds of people with heart disease, arrhythmias, hypertension, diabetes, other endocrine disorders and neurological disorders.  I saw many of those people when they were hospitalized, but seeing these folks in ambulatory care settings designed to enhance the learning experience for a psychiatrist would provide a better experience.   The process should probably start earlier in the fourth year of medical school.  Prospective psychiatrists should be focused on electives in neurology, medicine, and neurosurgery rather than psychiatry.

The teaching of psychiatry needs to address the practical concerns about diagnosis and treatment but also philosophical concerns.  Residents need to be familiar with the antipsychiatry philosophy and the existing literature that refutes it.  Residents need to know about the issue of the validity and reliability of psychiatric diagnoses and how that is established.  There is actually a rich history of how that came about but it could easily be summarized in one seminar.  One of the features that I was interested in when I was interviewing for residency positions was whether or not the program supplied a reading list.  There were surprisingly few that did.  This subject area would be a good example of required reading that is necessary to bring any prospective resident up to speed.

A good model to illustrate the difference between a neuroscience based approach as opposed to a symptoms based approach is American Society of Addiction Medicine (ASAM) definition of addiction on their web site.  Unlike the DSM collection of symptoms designed to pick a group of statistical outliers,  the ASAM definition correlates known addictive behaviors with brain substrates or systems.  Both of the standard texts in the field by Lowinson and Ruiz and the ASAM text by Ries, Feillin, Miller, and Saitz are chock full of neuroscience as it applies to addiction.  When I teach those lectures, I generally am talking about how medications work in addiction at that level but also how psychological and social factors work at the level of neurobiology.  I have not seen the DSM5 at this time, but I do think that it is time to move past defining every possible substance of abuse and associated syndrome and incorporating neuroscience.  Especially when the neuroscience in this case has been around for 50 years.   Residency programs need to teach that level of detail.

Psychiatrists need to maintain superior communication skills relative to other physicians and that means getting a good basic experience in interviewing and psychotherapy techniques.  At the same time - the psychiatrist of the future needs to be able to order and interpret tests including ECGs and MRI scans.  That wide skill base taxes every faculty except the very largest academic departments.  In the Internet age, there is really no reason that every residency program should not have access to the same standardized PowerPoints, lectures, and didactic material.  The ASCP Model Psychopharmacology Program is an excellent example of what is possible.  I would go a step beyond that and say that there should be a culture within organized psychiatry so that every psychiatrist should have access to the same material.  Establishing a culture where everyone (trainees and practicing psychiatrists alike) is up to speed and competent across the broad array of topics that psychiatrists need to be familiar with is a proven approach that is rarely used in medical education.

Psychiatry also needs to be focused on old school quality.  Not the kind of quality that depends on a customer satisfaction survey.  The issues of diagnostic assessment and appropriate prescribing at at the top of the list.  How do we make sure that every person consulting with a psychiatrist gets a high quality evaluation and treatment plan and not a plan dictated by a managed care company?  The University of Wisconsin has a paradigm for networking with all physicians in their collaborative Memory Clinics program.  I see no reason why that could not be extended to different diagnostic groups across the state.  The focus would be on quality assessment and to prevent outliers in terms of treatment.  It could be open to any psychiatrist who wanted to join and it could have additional benefits of providing university resources like online access to the medical library to clinicians in the field.

An interested, excited, and technically competent psychiatrist is the ultimate goal of residency and it should continue throughout the career of a psychiatrist.  That can only happen with a focus on professionalism at all levels.  My definition of professionalism does not include managing costs so that  a managed care organization can make more money.  Psychiatrists need to forget about being cost effective and get back to defining and providing the best possible care.   

George Dawson, MD. DFAPA

The Real Role of Biological Tests in Psychiatry

The idea of a "biological test" in psychiatry has appeared on the internet recently, primarily as a way to deny that psychiatric disorders exist.  The contention is that because there is no medical test for a psychiatric disorder - it must not exist.   Time to add a balanced view.

As a backdrop, most people do not understand the concept of "tests" in medicine until they have a problem and realize that the problem is not reflected in the tests ordered by their doctor.  That is a very common experience.  Some studies show that up to 30% of patients presenting to a clinic for investigation of a symptom never find out what the cause of that symptom was.  That is true even after they were given the usual panel of blood tests, imaging studies, and electrophysiological studies.  The assumption that symptoms and disorders in medicine are all diagnosable by a "test" is incorrect.

The second problem occurs at the level of test interpretation.  When a doctor orders a test they have to interpret it correctly and in many cases the idea of an "abnormal" test is blurred by biological variation.  The evaluation of back pain using imaging studies like MRI scans is a good case in point.  As people age there is a greater likelihood that an abnormal MRI scan of the spine is not necessarily the cause of their back pain.  That has very important implications for treatment and the physician interpreting the test may will definitely be influenced by their specialty training, their own personal experience, their knowledge and examination of the patient, and possibly treatment guidelines that they may be mandated to follow.  There is also the question of false positive and false negative testing.  The recent controversy about the utility of prostate specific antigen (PSA) testing for prostate cancer is another good example.  The current guideline says that this test has too many false positive results to use for treatment planning and further invasive procedures.  Even in the case where the diagnosis is made by a specific number there is always the question of whether the test number is accurate or not.  I have frequently repeated thyroid function tests that seemed to show hyperthyroidism only to see them in the normal range on repeat testing.  It is obvious to physicians that the so-called biological tests in medicine have their limitations and  always need to be interpreted in the context of a comprehensive evaluation of the patient.

How are biological tests currently used in psychiatry?  It turns out that there are a lot of applications similar to the rest of medicine.

1.  To detect a medical cause of a psychiatric disorder.  The DSM classification has an entire set of disorders that are caused by underlying neurological illnesses, endocrine disorders, and infectious diseases that need to be recognized and treated.  They often present as psychiatric disorders.  In my experience of treating people with severe problems, up to 15% of the psychiatric presentations had an underlying medical illness that either was a direct cause of the "psychiatric" symptoms or it made a psychiatric disorder worse.  In that case the psychiatrist has to be trained to order the appropriate tests, make the diagnosis and refer the patient for treatment of the underlying disorder.

2.  To screen for medical illnesses that complicate the psychiatric disorder or its treatment.  A good example here is screening blood tests and electrocardiograms based on the clinical assessment of the patient and the likelihood that a disease is present.  At times patients present with significant problems that require urgent treatment that they are unaware of.  A good example would be detecting complete heart block on an ECG because of a patient's responses to the cardiovascular review of systems and the fact that an antidepressant was going to be prescribed.

3.  To monitor the safety of biological treatments.  There is probably no better example than the FDA focus on cardiac conduction and how that can be affected by medications.  The most recent warning occurred with citalopram.  This antidepressant has been used for over a decade by psychiatrists and was widely considered to be a very safe medication. Both the FDA and the Mayo Clinic have guidelines about how this problem needs to be assessed and that is a combination of clinical assessment and electrocardiograms.  In some cases electrocardiograms and referrals to electrophysiologists are required.  In light of this information psychiatrists need to have access to these ECGs and a plan to address any abnormalities.  As specialists, it is common to see patients who are referred taking doses of citalopram that exceed current FDA guidelines and that may involve testing and a plan to modify the dose of antidepressant.

4.  To identify medical emergencies in patients who are being followed for a psychiatric disorder.  Many patients who see psychiatrists either do not have primary care physicians or are very reluctant to see them.  A psychiatrist in this position needs to make every effort possible to encourage the patient to establish primary care, but even then medical emergencies need to be recognized and appropriately triaged.  That can happen more quickly if testing is available to facilitate the referral.  If a patient presents with jaundice, medical consultants are more likely to see him quickly if some basic testing is done that can be discussed with the consultant.

5.  To identify neurobiological correlates of psychiatric disorders.  A common example is an abnormal brain imaging or electrophysiological study that was ordered because of an acute or progressive behavioral change.

6.  For heuristic purposes.  The classic example of a test done for heuristic purposes was the dexamethasone suppression test.  At various times it was suggested as a test for various forms of severe depression and suicide risk.  The test is rarely done today because of the false positive errors but it helped generate a couple of decades of research on the neuroendocrinology associated with psychiatric disorders.

Some of the articles currently out there on the internet deny the existence of psychiatric disorders because there is no biological test for these disorders like depression or schizophrenia.  That really does not differentiate psychiatric disorders from neurological or rheumatic disorders that may have some supporting markers but that in general depend more on pattern recognition and less on a gold standard or pathognomonic test.   From a paper that addresses that subject (1):

"Although the results are often useful, they can be misleading. Few tests yield results that are pathognomonic for particular diseases. For these reasons, test results for autoantibodies alone are insufficient to establish the diagnosis of a systemic rheumatic disease; they must always be interpreted in the clinical context. Positive results for tests such as the ANA test are seen quite commonly in patients with nonrheumatic diseases and even among normal, healthy persons..."

The key sentence here is:  "Few tests yield results that are pathognomonic for particular diseases."  That would mean that in fact there are few so-called gold standard medical tests that confirm or deny the existence of a diagnosis.  Up to 30% of people presenting to a medical clinic for an evaluation of symptoms will never have a diagnosis to explain their symptoms no matter how many tests they have.  People with real illnesses often are frustrated by the fact that the test results they get are often equivocal.  Obvious conditions that have no biomarkers range from migraine headaches to Alzheimer's Disease.  I don't think that any rational person would suggest that neither of these conditions exist.  People who have first hand experience with severe mental disorders know that the profound emotional and cognitive changes that they see in their friend of family member is real - whether there is a biomarker or not.

George Dawson, MD, DFAPA

Reference:

1:  Arthur Kavanaugh, Russell Tomar, John Reveille, Daniel H. Solomon, Henry A. Homburger; Guidelines for Clinical Use of the Antinuclear Antibody Test and Tests for Specific Autoantibodies to Nuclear Antigens. Arch Pathol Lab Med 1 January 2000; 124 (1): 71–81. doi: https://doi.org/10.5858/2000-124-0071-GFCUOT

The Myth of the Psychiatrist as Bogeyman

Probably the most annoying aspect of being a real psychiatrist is the constant attacks on the profession.  Psychiatry is unique among medical specialties in that there are a number of philosophies, special interests, critics for profit, and some might say cults out there who generate a constant barrage of criticism of widely varying quality.  There are even attacks from within the field.  Most medical specialists are concerned primarily with patient care, but that is not true for the self appointed critics of psychiatry who like to attack psychiatry at any possible point in time.  In this negative atmosphere - real psychiatrists like me are dedicated to patient care and continue to provide a valued service that has recently been demonstrated to deliver treatment results on par with other medical specialists.  Our reason for existence in the negative environment is the sole fact that we will treat severe problems successfully that nobody else will approach.  Unique psychiatric training allows us to do that.  So how do we explain the incongruence between what real psychiatrists do every day and how they are treated in the media?  It is basically a two step process.

The first step is looking at what is said in the media and what it really means.  When Senator Grassley began investigating psychiatrists and their relationships to the pharmaceutical industry on a selective basis ignoring other medical specialties despite widespread relationships between other specialists and the pharmaceutical and medical device industry what was the real message there?  When the DSM5 is critiqued for being an inaccurate device designed to make as much money for the pharmaceutical industry and organized psychiatry as possible - what is the real message there?  When psychiatric diagnosis is described as being totally arbitrary and lacking validity by people who think that validity has something to do with a laboratory test, what is the real message there?  Let me translate it for you.  It means that psychiatrists are at best totally incompetent and at their worst greedy, dishonest, manipulative, unethical, and interested basically taking money for a worthless diagnostic and treatment exercise that frequently harms people.  In other words perpetrating fraud.  There is really no way to sugar coat it.  If all of the critiques of psychiatry in the media are accurate - that is the only logical conclusion.   If you accept that position psychiatry has been devalued as an essentially worthless medical specialty.

The second critical step is to ignore all of the flaws associated with the rest of medicine.  Let's forget the fact that 30% of patients entering a medical clinic will not get an adequate explanation for their symptoms even after extensive investigation with those gold standard tests.  You know - the tests that mean the diagnosis is "valid".  Let's forget that reliability estimates for medical diagnoses - even using those gold standard tests are no better than the so-called poor reliability estimates of psychiatric diagnoses.  Let's forget the fact that diagnostic and treatment errors in medicine are common.  Let's forget that treatments for medical disorders generally carry a much higher risk of death and complications.  Let's forget the fact that patients with factitious disorders get admitted to general hospitals for extended periods of time and pretend that only psychiatrists can't detect a pseudopatient.  Let's forget the fact that significant numbers of medical diagnoses are routinely made in the same way that psychiatric diagnoses are made.  Let's forget the fact that consensus medical diagnoses by experts are common within all medical specialties.  Let's forget the fact that other specialists work for pharmaceutical and medical device companies.  Let's forget the fact that many specialty organizations have revenues from industries that easily exceed the revenue stream of the American Psychiatric Association (APA).  Let's forget an entire list of imperfections in the practice of medicine and pretend that general medicine is perfect for the sake of comparison with with an imperfect psychiatry.  We have succeeded in overidealizing medicine.

That two step dynamic of devaluing psychiatry on a purely arbitrary basis and idealizing the rest of medicine and choosing not to apply the same criticisms that are used in the case of psychiatry is the recipe for the psychiatric bogeyman that you keep reading about in the papers.

If you really believe that there is a psychiatric bogeyman - I have a bridge in Brooklyn that I can sell you.

George Dawson, MD, DFAPA