“Just A Giant Bowl of Doodoo”

You know, I just saw the articles about the DSM-5 and psychiatry in general written by a couple of columnists along with the response by American Psychiatric Association (APA) President, Dr. Jeffrey Lieberman, links to which for convenience follow:

‘Unspecified Mental Disorder’? That’s crazy — Health & Wellness — Sott.net

Heroes of Uncertainty – NYTimes.com

PsychiatryOnline | Psychiatric News | News Article J. Lieberman Psychiatry Nothing to Be Defensive About

You know, this will sound like I’m more disorganized than usual, but I was reminded of a comment I read on a completely unrelated story about dementia risk being reduced by putting off retirement, Dementia risk reduced by putting off retirement, study suggests – CBS News.

Not that I haven’t been thinking about early retirement, but it wasn’t so much the article itself that struck me; it was one of the comments about the article, or part of the comment, “This article is nothing but a giant bowl of doodoo.”

Now it was probably because I was a little tired when I read it at the time, but I thought it was so funny that I chuckled about it for hours afterward. What if it were that easy to dismiss every position with which we disagreed?

But despite the erudition and energy of Dr. Lieberman’s response to the New York Times and Wall Street Journal pieces expressing frustration with Psychiatry’s “semi-science” approach to mental illness, I couldn’t help thinking to myself,

Why does an article entitled “Psychiatry: Nothing to Be Defensive About” sound, well, a bit defensive? If there’s nothing to be defensive about, then why respond to David Brooks or Leonard Sax at all?

Or why not just think, “These articles are nothing but a giant bowl of doodoo.”

Because they are not doodoo, not completely anyway. I’m not so sure I disagree with Brooks when he says “The best psychiatrists are not coming up with abstract rules that homogenize treatments. They are combining an awareness of common patterns with an acute attention to specific circumstances of a unique human being.”

I say things like that to my residents all the time, although not so eloquently. I hope that doesn’t make me a traitor to my profession.

And when Sax says the DSM-5 diagnostic schemes highlight fuzziness and cautions U.S. patients to either “move to Europe” or “exercise extreme caution” when visiting an American mental health clinician, and says “Realize that the official guidelines now in force are not guidelines at all, but rather a license to diagnose anybody with anything”…why not take it with a giant bowl of doodoo?

Just an aside, I wasn’t so sure, either, about Dr. Lieberman’s  last paragraph:

Our understanding of the relationship between the brain and mental disorders may have been slow to develop, but recent advances in research have shown us that they are biological in nature and caused by genetics and environmental factors. Patients are not responsible for their mental illness, and psychiatrists are doing their best to recognize and treat mental disorders and help patients as best we can within the limits of our knowledge. For this noble mission, we have nothing to be defensive about.

As you know, I think there’s not just one authority about psychiatric diagnosis (see The Geezer’s Triumvirate for Psychiatric Diagnosis – The Practical Psychosomaticist) and I’m refreshing my memory about the perspectives of psychiatry, which include the premise that psychiatric disorders are not all diseases (see “Systematic Psychiatric Evaluation” by Drs. Chisolm and Lyketsos). Some of them are more about life stories, behavior, or dimensional models for what can go wrong with us and for which there are no lab tests. So I probably would not say categorically that all “patients are not responsible for their mental illness” nor do I think all mental illnesses are completely “biological in nature and caused by genetics and environmental factors.”

I think patients with psychiatric illness also make choices, some of them healthier than others. And we’re all doing our level best, especially when we collaborate.

By the way, there are many psychiatrists who think the DSM-5 has great clinical utility [1]. I also think Allen Frances’ dozen general tips should be taught to all trainees, The Dirty Dozen on Dr. Allen Frances’ General Tips for Psychiatric Diagnosis – The Practical Psychosomaticist.

All of the authors think they’re right. All of the authors except those of the DSM-5 criticize the others about their approaches. It’s hard not to notice that. It doesn’t make the DSM-5 holy.

But, in my opinion, an awful lot of people are out there saying, “Your ideas are just a giant bowl of doodoo.” If more of us listened to each other, maybe life would be more like a giant bowl of cherries.

1. Moscicki, E. K., et al. (2013). “Testing DSM-5 in Routine Clinical Practice Settings: Feasibility and Clinical Utility.” Psychiatr Serv.
OBJECTIVE This article describes the clinical utility and feasibility of proposed DSM-5 criteria and measures as tested in the DSM-5 Field Trials in Routine Clinical Practice Settings (RCP). METHODS RCP data were collected online for six months (October 2011 to March 2012). Participants included psychiatrists, licensed clinical psychologists, clinical social workers, advanced practice psychiatric-mental health nurses, licensed counselors, and licensed marriage and family therapists. Clinicians received staged, online training and enrolled at least one patient. Patients completed self-assessments of cross-cutting symptom domains, disability measures, and an evaluation of these measures. Clinicians conducted diagnostic interviews and completed DSM-5 and related assessments and a clinical utility questionnaire. RESULTS A total of 621 clinicians provided data for 1,269 patients. Large proportions of clinicians reported that the DSM-5 approach was generally very or extremely easy for assessment of both pediatric (51%) and adult (46%) patients and very or extremely useful in routine clinical practice for pediatric (48%) and adult (46%) patients. Clinicians considered the DSM-5 approach to be better (57%) or much better (18%) than that of DSM-IV. Patients, including children age 11 to 17 (47%), parents of children age six to ten (64%), parents of adolescents age 11 to 17 (72%), and adult patients (52%), reported that the cross-cutting measures would help their clinicians better understand their symptoms. Similar patterns in evaluations of feasibility and clinical utility were observed among clinicians from various disciplines. CONCLUSIONS The DSM-5 approach was feasible and clinically useful in a wide range of routine practice settings and favorably received by both clinicians and patients.

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