Monday, April 12, 2010

This is OUR DSM (Forget About Clinicians)

As you know, I have begun work here on a People’s DSM, with my own version of what depression and bipolar should look like. I suffer from no delusions that clinicians will actually take this seriously. As the title says, this is the People’s DSM, not the Clinician’s DSM.

Let me back up a bit and explain:

The DSM-III of 1980 was intended as a means of clinicians communicating to other clinicians. A nurse on an Indian reservation and a celebrity psychiatrist in an Upper East Side practice talking on the phone, in theory, would each know what the other meant by “depression” or “bipolar” or “schizophrenia.”

In order to accomplish this, however, the DSM was forced to err on the side of simplicity. A lot of the vital nuances were lost, which tended to defeat the purpose. In any case, the DSM was supposed to be the Doctor’s Dictionary. Nothing more.

The totally unexpected overnight success of the DSM-III, however, changed all that. In no time, a mere dictionary morphed into the diagnostic bible, not to mention the clinician’s cheat sheet, with the quickie symptom checklist standing in for sophisticated evaluations and clinical wisdom.

With the DSM becoming the means by which clinicians got paid, total corruption set in, guaranteeing that diagnostic psychiatry would be stuck in a simplistic 1980 mindset forever. From our perspective as patients and loved ones, this meant our own learning would be very narrowly based. The Doctors’ Dictionary sadly turned into The Patients’ Primer. As I explained in an article on mcmanweb last year:

Go to nearly any mental health website (not this one), and you will be treated to descriptions of depression and bipolar based on DSM-IV criteria. Read a book, glance at a brochure, take an online test, talk to your doctor - all DSM all the time.

This is where I got involved. It’s not my place to tell clinicians how to do their jobs. But with our lives on the line, we cannot afford to be as misinformed as they are. That’s what Knowledge is Necessity is all about. On my website, I introduced my DSM Report Cards and The People’s DSM this way:

In February this year, the American Psychiatric Association's DSM-5 Task Force issued its Proposed Revisions to the next edition of the DSM, due out in 2013. The proposals, if enacted, will do very little to change the depression and bipolar diagnoses, but they do provide us with a golden opportunity to rethink issues that we tend to take for granted.

And further on:

Don't worry, no one listens to me. But both exercises are food for thought. Without awareness into our respective conditions, we are at the mercy of clinicians in a hurry. Now, more than ever, knowledge is necessity.

A few hours after I happened to write that, I attended a NAMI "In Our Own Voice" presentation. One of the presenters, let’s call him Adam, mentioned that at different times he had been diagnosed with depression, bipolar, and schizophrenia. Someone in the audience happened to ask why the schizophrenia diagnosis.

We pick up the account on a blog I write for HealthCentral’s BipolarConnect:

Adam explained that when he was depressed he was also experiencing psychotic delusions, which is why his doctor assumed he had schizophrenia. I turned to a friend in disbelief.

This is crazy, I whispered to my friend, a schizophrenia diagnosis on the basis of just one psychotic episode? The doctor has to be an idiot.

Often I get the impression psychiatrists are doctors not smart enough to be proctologists. I went on to say that the current DSM, flawed as it was, should have led Adam’s psychiatrist to a far less extreme diagnostic call. Which leads us to the $64,000 question:

So would an improved DSM have afforded Adam’s doctor greater guidance? No, sad to say. The current DSM was more than adequate, and therein lies the problem: The best diagnostic manual in the world is only as good as the doctor reading it.

As I said to my friend, there are too many idiot doctors out there. Way too many.

So, back to why we are here:

The smart doctors are already practicing psychiatry according to The People’s DSM. All I did was gather their insights, along with yours, and tie them in a bow. So smart clinicians hardly need to change their ways. And the dumb ones who badly need remedial education, well, they’re too dumb to know that.

In short, the People’s DSM is for our benefit only, to get us thinking about issues vital to our well-being. But I would add this qualifier: It is by no means anyone’s final word. This is supposed to be the start of the conversation, not the end of it. The official DSM had the opposite effect.

So, never mind what clinicians think. It’s what WE think that is important. They’re the ones who get paid, but it’s our lives on the line, not theirs. As I keep saying over and over and over, Knowledge is Necessity.


Anonymous said...

Amen, amen, amen. Have two kids (now adults) who are on the mood spectrum --- the stories I can tell about incompetent pdocs - the worst one was supposed to have been the best and brightest at one very big clinic/hospital where we live! The bottom line is that the 'consumer' needs a pdoc who is respectful, puts patients before their own ego, doesn't mind getting grilled with lots of important questions about symptom management and med side effects, and, in fact, encourages this sort of dialogue. Appreciate all your work! You have been an important resource for my family over the years.

John McManamy said...

Many thanks, Anonymous. You made my day.