Monday, February 15, 2010

My Draft DSM-5 Report Card: Hint - Don't Expect Liberal Use of the First Letter of the Alphabet

My previous two pieces on the draft DSM-5 hinted that we should rip it up and start over. Okay, okay, it said so right in the title - Part I and Part II - but I didn’t think people actually read those things. Now that you know where I stand, in future blog pieces I’m going to start issuing DSM-5 report cards, complete with passing and failing grades.

I will start by breaking down the DSM-5 draft proposals for depression, then in later pieces move on to bipolar and the other mood disorders. Then over to schizophrenia and psychosis, anxiety, ADHD, the personality disorders, and on and on down the line until I run out of material or run out of steam, whichever comes first.

But before I do, my disclosures:

I am living with a mental illness. My diagnosis is bipolar I mixed, which is a fairly accurate reflection of my condition, as it’s one of the few areas of mood disorders that the current and previous editions of the DSM actually got right.

I mean, seriously, how could they not get it right? You should see me when I go crazy. You don’t need a panel of experts to determine my condition. The cast of Jersey Shore sleeping off a group hangover could make the right diagnostic call, as could Paris Hilton contemplating a broken finger nail

And in case people might mistake a crazy raving maniac (me) for a crazy raving individual with schizophrenia, it just so happens that I deliver my raging insults in four-syllable words arranged in perfect ironic sequences, with precision Pythonesque timing.

I’m not through. Very rarely do I get manic. Depression has been the bane of my life, so naturally when I first sought help, the psychiatrist who evaluated me wound up diagnosing me with unipolar depression and prescribing an antidepressant. This had me bouncing off the walls and ceiling, which, of all things, brought me out of my suicidal depression in a hurry and probably wound up saving my life.

But still, the shrink had no way of differentiating unipolar depression from bipolar depression? See what I mean about disclosure, here? This is my friggin’ life on the line. My life! Talk about personal bias.

Anyway, here I am conducting my own failure analysis: If it’s unipolar depression, the antidepressant has a good chance of getting me better. If it’s bipolar depression, my ass is grass on an antidepressant. This isn’t like a waiter getting my order wrong and bringing me the chimichanga instead of the carne asada platter. This is major.

Yet a doctor of medicine specializing in psychiatry screwed up. Amazingly, I discovered, this was no fluke. Psychiatrists do this all the time. So, either psychiatrists are doctors not smart enough to be proctologists or there was a major system failure that could be laid at the two left feet of the DSM-IV.

Moving on, I have lots of other crap going on. In certain situations, I freeze like a deer in the headlights. In others, I would swear my thoughts were coming from outside my brain (or, at least, my neurons weren’t taking any of the credit). Other times, in social settings, it’s either as if I’m invisible or as if everyone else is backing slowly toward the exits.

There’s no DSM disorder for this type of stuff, or if there is I have yet to find it. The best I can come up with is I experience a “little bit of this” and a “little bit of that.” As in a little bit of anxiety and panic, a little bit of attention deficit disorder, and a little bit of a whole shit load of personality quirks.

Granted, by reading up on the full-blown versions of these DSM conditions I am able to acquire an insight into why my brain operates like a precision Swiss watch with a few jewels missing, but it would be nice if the people I entrust my life to had this appreciation, as well.

Namely, it’s not enough for me to get my official DSM-IV bipolar under control. If I want the kind of life that most others take for granted, I have to learn to manage my other weird shit, as well. And maybe if psychiatry had a system for triangulating all these various symptoms across the diagnostic categories then maybe we could really find out what is going on in our brains and actually do something about it.

So you see, compared to the academic researchers working on the DSM-5, I have competing personal interests all over the place. By contrast, the DSM-5 people have only minor concerns such as past ties to the drug industry and their various convoluted reasons for wanting to keep things the same forever.

Past industry ties, it turns out, are a much bigger problem than I would have thought. The illnesses in which meds are typically the backbone of treatment (such as mood disorders) coincide with the sections of the DSM involving the fewest proposed changes. By contrast, the areas of the DSM where Pharma is invisible (such as personality disorders) involve by far the most sweeping changes.

This pattern also coincides with who rules the roost in academia and who are seen as the poor relations. This bears much closer scrutiny in future pieces.

But by far the most disturbing factor about competing interests is that those working on the DSM-5 didn’t evidence even remotely similar ones to mine. Otherwise, they might have cared about the homework they turned in.

As you can see, my first grade is not about to be an “A” for effort.


BN said...

Thanks for a brilliant read, John, as usually! We should have you write the new chapter on bipolar for the DSM!!! Gonna go read the rest of your report cards now!

Anonymous said...


I have a son that is just been diagnosed as bi-polar. He is on lithium but in speaking with him today his problem is depression not mania. are anti depressants wrong for him?