Stick to your knitting, please.

Not too long ago I had a look at this on what I am learning is the outlet of all medical knowledge in the blogosphere, KevinMD. I have another bone to pick with Kevin, M.D. later.

This one, however, is about a post that took as its jumping-off point a book by Allen Frances about the ins and outs of developing DSM-V.

So here’s where things started to go wrong:

It defines mental illness, and in the process also defines what is normal.

Is that what it does? Funny, I have never once consulted a DSM manual (to the extent that I do) to figure out if someone was normal.

Then, we round the bend with this one:

Objectivity is often mistaken for science and truth, but no line cleanly separates disease from normality. Both reside in the Gaussian curve.

No. No, they don’t. Not at all.

The author is a radiologist. I am wondering, when she looks at a chest radiograph, how she decides what percentile of pneumoniation the patient has. Is it 70th percentile, “borderline pneumonia?” 95th percentile, “severe pneumonia?” Where, on the Gaussian pneumonia curve, does one draw the line for “having pneumonia?”

I note the slippery word “disease.” Is what we mean by “disease” being in the 5th or 95th percentile on some Gaussian curve?

It’s not what I mean when I say that. When I have the flu, I’m not saying “I believe that I am currently in the 95th percentile of malaise, fever, rhinorrhea, and myalgias.” What I am thinking is

Well, what I’m thinking when I have the flu is mostly unprintable.

Disease, though, fundamentally, involves a qualitatively abnormal state, rather than a quantitatively abnormal one. Which is why so many of psychiatry’s conditions fit awkwardly there.

I really, really don’t want to get in the business of “What fools these mortals be” with non-psychiatrists. Because, most mortals are not fools and there are plenty of fools in psychiatry.

However, in the words of the not-exactly-immortal-but-with-remarkably-little-body-fat Henry Rollins, “Knowledge without mileage equals bulls–t.” When I hear someone talking about what I do, and I detect a distinct lack of mileage in their conceptualizations, I will listen. But expect a jaundiced eye.

I have a theory, and it is fundamental to the point I’m about to (try to) make. Always good to state your assumptions at the outset, yes?

From talking to lay folk, I think people appreciate that there are various propensities to negative human emotions and behaviors; sadness, anger, anxiety. That is, undoubtedly true. The variation in those emotions or behaviors is fundamental to current theories about personality.

Here’s where I think common assumptions diverge from reality: Psychiatry is about identifying people on the “bad end” of this distribution, and medicating or therapizing them to get them closer to the “good end.”

Mind you, I think in some cases that’s close to true. However, there are plenty of cases where it isn’t; and assuming that’s all there is to it leads to a lot of confusion.

When looking at someone with schizophrenia, I am not trying to assess what percentile on the auditory hallucinations Gaussian curve this patient is. There is no Gaussian curve for hearing the CIA agent who is monitoring your thoughts from across the street talking through your vents.

Then we have mania. Alzheimer’s Disease. Huntington’s Disease. Catatonia. Lead intoxication. Highly recurrent and chronic depression. OCD. Panic disorder.

It seems that every time there is any sort of disturbance in The Force around psychiatry, the media and the public erupt into a roil about how psychiatrists are pathologizing or medicalizing everything. This tends to center on the most ambiguous and fuzzy categories in psychiatry at the time, while ignoring how very little the most severe and clear cut diagnoses have really changed since, well, Hippocrates. Probably earlier.

Here are some things worth knowing:

  1. Nobody who actually uses the thing, including the people who write it, thinks the DSM is anything resembling a “Bible of Psychiatry.” If it were, it wouldn’t get changed around every two decades or so (thus creating the disturbance in the Force previously mentioned).
  2. Psychiatrists do not prowl the streets looking for people to medicalize and medicate. By and large, people come to us; and they typically do it because they are suffering. (Some are forced. They may be suffering too, but sometimes they’re just making other people suffer. That’s a different dynamic, and tricky.)
  3. A whole lot of people who come to see us are really just sick. Really. That’s it. They have major depression, just like their mother and grandfather; or they have manic-depressive illness or schizophrenia.
  4. When you have somebody in front of you who is suffering and asking you for help, you @#$#ing try to help, whether what causes that suffering fits into some neat category or not. In order to do that, you have to write something down for why you’re helping and (sadly, in many cases) the DSM is the lingua franca to do that.

From where I sit, the fundamental problems with the DSM fall into two areas: lump or split, and diseasifying in the name of reliability.

The lump or split problem has to do with the fact that the most disease-like entitities in psychiatry have funny variations. It may be that people with bipolar disorder with really frequent episodes need to be treated in a different way than people who have more intermittent episodes. Some people get psychotic during their episodes, others don’t. Should we have separate categories for these things, or not? Notice it’s not a question of whether such things happen. We know this is real, it’s just how we write it down. One place this has played out recently is in the substance use disorder categories, in which the “abuse” and “dependence” distinction finally has been dumped in favor of a severity specifier. There are those who will look at the fact that the “Substance Use Disorder” prevalence will increase and screech about overdiagnosis; and then there are those who will note that the overall picture really just looks like those who fell in the old “abuse”category now fall into the “mild SUD” category.

The diseasifying problem mainly has to do with things that don’t fit the disease mold so well, but that we can still help out with. Often we can help quite a lot. Things like personality disorders, addictions, and maybe some stuff like generalized anxiety disorder or ADHD. In these things, overlearned behaviors, or being at the wrong end of some Gaussian distribution(s), are what lead to the suffering. Of course, it could be in twenty more years we find some reasonably qualitative-looking pathophysiologic difference in these folks, and it turns out the disease model will work better.

Even so, it would be a lovely, lovely thing if somebody could say “This person is 95th percentile on Neuroticism and 2nd percentile on Agreeableness and the fear, anger, distrust, and hostility with which he approaches the world is limiting his life and causing all kinds of frustration and trouble for him.” However, the medical system (and the medical payment system) is built around the disease model, and for all the furor when something iffy gets talked about in disease terms, heaven help you if you want to help people like that and keep your shingle out, ’cause nobody is gonna pay unless it’s real,  by which I mean (sing along with me) a brain disease.

If people are really so concerned about medicalizing everything, here’s what I would suggest:

  1. Keep your eye on the most disease-like entities in psychiatry. When you get bent out of shape about how the prevalences in some other categories change, notice how little the prevalence of schizophrenia, bipolar disorder, major depression, panic disorder, OCD, etc. change. Then, breathe deeply and calm yourself. They’re not coming to drag all you normal folks in to a psychiatrist’s office and shove pills down your throat.
  2. With respect to the ones where the prevalence does change around, first ask how would I figure out what the right prevalence is if I were trying to do this? If you simply think any increase is a mistake, you have an implicit bias. Figure out what it is, and question it. (Same the other way.)
  3. If you would like to stop pharmaceutical companies from influencing diagnosis, stop the direct advertising and push for limitations on how they influence doctors. The place to start with the latter, by the bye, might well be with primary care physicians (including pediatricians).
  4. If you would like to stop stuff that isn’t particularly disease-like getting diseasified, push for a world where a professional can get paid to help someone who is suffering so long as a clinical entity can be reasonably defined and there is a treatment that can work. Then the everything-is-a-disease crowd don’t have a built-in advantage.
  5. If you really, really, really care about vague diagnostic entities, diseasifying stuff that doesn’t fit disease reasoning very well, and so forth; psychiatry may not be the only place to look. Look up the history of fibromyalgia, or think about obesity, diabetes, cardiovascular disease, smoking, and on and on. That line of reasoning has led me to think that psychiatry is mainly special in that we are earlier in our history and we know we are often missing the boat. Perhaps such humility, applied to the rest of medicine, might yield some interesting results.

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