Q. Here is something I struggle with—unless there is extremely clear
evidence from the past of the primary indicators of psychosis, I think it’s quite difficult to distinguish between residual
schizophrenia and schizotypal or schizoid personality disorders. Thoughts?
A. But that’s the point: to diagnose residual schizophrenia, there MUST
be clear evidence of past indicators of psychosis, otherwise the “A” criteria will not be fulfilled.
Q. In your book, DSM-IV Made Easy, you made a clear distinction between schizoaffective
disorder and schizophreniform disorders. which [diagnosis] would I use for someone who presents with a first episode of symptoms
and the symptoms resolve within six months?
A. Depends on the symptoms. If the patient meets criteria for the mood symptoms
and psychotic symptoms of schizoaffective disorder, then that’s the diagnosis, regardless of whether it resolves or
not. If the patient meets criteria only for psychosis and it resolves, schizophreniform psychosis is the correct diagnosis.
Q. An undergraduate student majoring in psychology, I am trying to find out
where in the DSM-IV does self mutilation fit?
A. Self-mutilation is not a diagnosis. It comes up as one of the criteria
for Borderline Personality Disorder. Of course, it can be found in other diagnoses as well, though not as a diagnostic criterion.
Q. I need information on 40 year old well educated man molesting two young
family members ages 10 & 11 over a period of two & half years. Did not
know where to start, searching internet for information.
A. The specific pertinent DSM-IV diagnosis would be in the sexual paraphilias
(pedophilia). However, you’d need to know an awful lot more about the person, including family history of mental illness,
personal history of mental illness (does the person have bipolar or psychotic disease). What about substance abuse, which
can facilitate child abuse. Is there a personal history of child abuse? Searching on “child sexual abuse” with
Google netted me more than 2 million hits. The real point: you need FAR more information than is given in your summary.
Q. I hope that you can answer this question for me. I am confused as to whether
fetal
alcohol syndrome is diagnosed on Axis I or III. The ICD9-CM code of 760.71 suggests Axis I but as a contributor to mental
retardation Axis III is suggested. Thanks in advance if you can help.
A. The fetal alcohol syndrome is a physical condition included on Axis III.
You would make whatever mental diagnoses are appropriate on Axis I and II.
Q. Can you tell me the criteria for ADHD NOS and how many have to be met to
qualify?
A. There are no criteria for ADHD NOS, or any other “not otherwise specified,”
for that matter. That’s the function of NOS: a wastebasket where people who don’t fully meet criteria for diagnoses
that do require criteria.
General aspects of the DSM
What do the initials DSM mean?
Q. What does “DSM” stand for?
A. DSM stands for “Diagnostic and Statistical Manual” (of
the American Psychiatric Association). Some clinicians who don’t like to use it say it stands for “Damned Silly
Manual,” but we won’t pay them any mind.
Who wrote the DSMs?
Q. Can you give me the dates that were released all of the DSMs and can you
tell me who wrote them. Thank you for your time.
A. Each DSM has been written by committee. The person in charge of DSM-IV
and the current chairman was/is Allen Francis; Robert Spitzer was DSM-III and DSM-III-R. DSM-IV was 1994; DSM-III-R was 1987;
DSM-III was 1980; DSM-II was 1968; DSM-I was 1952.
Doubts about DSM-IV?
Q. I am writing to tell you that your book “DSM-IV Made Easy”
is a wonderful addition to the range of books out there which attempt to shed light within the murky waters of the DSM-IV
and its subsequent and potential updates. As a layperson with more information than education, your book has been an invaluable
learning tool. The Tips are right on point...no pun intended...I find myself with a question in my mind, only to look a bit
further to see that a Tip has the answer for me, or points in the direction I should look for more information. Likewise,
the “case studies” give me an anchor, offering a picture of a “person” that I can remember when all
the little details start to run together.
I have a question, and I’m not sure even how to ask it, but here goes. In many parts of the DSM variations, I feel like the authors are “painting bull’s
eyes around arrows”. The disorders themselves seem to sometimes be a creation of the diagnoses, if that makes sense.
I’m also confused about the “either/or” aspect of thinking about and defining disorders, and the labels
which are the typical products of that kind of thinking. My question is: Do you have doubts about the wholehearted embrace
by the psychiatric world of the DSM classification model? (The fact that you wrote this book makes me think that you understand
the limitations and possibility of misuse of the DSM itself--that’s why I’m asking you.)
A. Of course, I have my concerns about DSM-IV. But then, nearly every thinking
psychiatrist has reservations about some parts of it. Whereas much of it was put together from the best scientific studies,
some (such as Acute Stress Disorder) was cobbled together to fill a space—an example of your lovely metaphor about painting
bull’s-eyes around arrows.
However, the prospect of life without the DSM is so much worse. In fact, when
I was in training many years ago, we didn’t have criteria for much of anything. The reason that I am so interested in
the topic undoubtedly relates to the fact that I was trained in St Louis at Washington
University, which is/was the cradle of the modern DSM.
As to misuse, although the criteria are misused by some, my principal concern
is that they are not used enough. To date, there are NO studies that show the extent to which ordinary practitioners actually
adhere to the spirit, let alone the letter, of the criteria, even for the major mood and psychotic disorders.
Bias in the DSMs
Q. Do you think that some of the diagnoses in the DSM-IV are biased? Some of
these diseases are only directed towards women, and aren’t some of the behaviors that are presented as “diseases”
just something the law has chosen to call criminal? The DSM-IV is influenced by society, politics, and the people who construct
the categories.
A. Bias is, to a degree, in the eye of the beholder. There are certainly problems
with DSM-IV, one of which is that certain disorders crept in that have less scientific basis than is the stated ideal for
the document as a whole. However, reading between the lines of your question, I do not believe that DSM-IV is biased against
women. The fact that some disorder are found largely in women is because, well, that’s what the research has turned
up. Some disorders, such as antisocial personality disorder and all of the substance use disorders, are found mostly in males,
but that doesn’t mean the researchers are biased against men. Actually, DSM-IV goes to some lengths to point out that
we should not label a person with a disorder just because of behavior our society frowns upon (or worse). However, in many
cases the research still needs work. And I feel that we must remain ever-alert to the possibility of bias, and design our
studies and our treatments in such a way that we will identify and defeat bias if ever we find it.
DSM-VI?
Q. I am teaching the counselors in the Drug & Alcohol Program, and I have
a question. We were using DSM-IV to diagnose the alcoholics. But now I have
heard that DSM-VI [sic] is a little different from DSM-IV in the criteria
for alcohol abuse. (There are 7 criteria in DSM-IV and in only 4 in DSM-VI.) I cannot learn about DSM-VI anywhere. Would you explain for me when DSM-VI was made, and should it be used instead of DSM-IV?
A. You’ve been misinformed. DSM-IV is still in force, and will be until
around 2012. That’s the date that we estimate DSM-V (five!) will be published. DSM-VI (six) hasn’t even been thought
of, as yet. I think the 4 criteria you are taking about are for substance abuse,
as opposed to 7 criteria required for substance dependence. They are two different diagnoses in DSM-IV.
Flash cards
Q. I am a new Psy. D. student and I am taking adult psychopathology. I am wondering
if you have flash cards for the DSM-IV-TR classifications or know somewhere that I may get them. Thank you.
A. I don’t have them, but I Googled the net and found them here:
http://shop.store.yahoo.com/oakwoodpublishingcompany/dsmivflascar.html
They cost $25. But frankly, I think you’d get more out of the exercise
by making your own for the really important diagnoses -- mood disorders, anxiety disorders, psychotic disorders, substance
use, and so forth.
DSM versions
Q. I was wondering if you could tell me when the updates where produced
for DSM-3R, 4, and 4R. Also, is 4R the same as 4TR?
A. DSM-III was 1980; III-R was 1987; IV 1994; IV-TR 2000 (which is the
revision of just a few criteria, plus a lot of new research findings, from the 1994 version. DSM-V is due out about 2012.
DSM-III versus DSM-IV:
Q. I am currently putting together some notes on this subject, here in
England. Could you answer me two quick questions. 1. Are there many differences between DSM III and IV ? 2. Do culture-bound
syndromes appear in either of these ? Thank you
A. Unhappily, the answer to the first question is not so quick. I can’t
go into it all -- not enough electrons in this machine. The short answer is “yes.” There were many diagnoses added,
virtually all criteria were changed in at least some way, and the philosophy of diagnosis was changed in the years from 1980
to 1994. To see the total picture, you’ll have to compare the two volumes. I will make explicit one change in philosophy,
however: DSM-III disallowed a diagnosis of one disorder if there was another disorder diagnosed from earlier in the book (hierarchical
diagnosis). By DSM-IV, this had been essentially eliminated, so that, for example, a clinician could make a diagnosis of both
a mood disorder and an anxiety disorder.
The second question is easy. Culture-bound syndromes
appear only as a glossary in Appendix I (that’s the 9th appendix) of DSM-IV.
Culture-bound disorders
Q. Can you let me know the degree to which your “DSM-IV Made Easy”
text provides information / guidelines about culture (i.e., how to ensure that one’s lack of familiarity with a client’s
culture or context does not result in misdiagnosis) or about culture bound syndromes?
A. Sorry, this isn’t a topic that I’ve addressed in my book.
You will require a somewhat more specialized text, I believe. Although the actual DSM-IV does list culture-bound syndromes,
it doesn’t provide the degree of depth you want, either. Here is one site that can help. With Google, you’ll find
scads more.
http://anthro.palomar.edu/medical/med_4.htm
What is normality?
Q. Why does the DSM omit any discussion of normality?
A. You ask a really good question. The DSM-IV (and all its cousins) exist
to try to provide practical definitions of what is not normal, i. e., diseased (or disordered, as the manuals prefer to say).
In truth, this is a somewhat less arduous task than trying to define normality, which has any number of different definitions,
depending on your point of view (is it freedom from illness? is it that which is average? is it simply feeling ok?) Each of
these definitions has its problems, and its adherents. Theoretically, you could say that DSM-IV does define normality in the
sense that, take away all that it does define, and what is left must be normal. But that is a decreasing portion of the general
population. Many of us who worry about these things feel that we have gone somewhat overboard, and may soon be at the point
of calling a huge portion of the general population “abnormal.” Every once in a while, DSM-IV does mention, it
its discussions of the differential diagnosis of one disorder or another, to, for example, “realistic concerns”
(in Agoraphobia without History of Panic Disorder). This is pretty close to talking about normality, but it doesn’t
come up nearly often enough. And it is, I’m afraid, only definition by example, which isn’t the best way to go.
Axis system
Q. My daughter has a diagnosis of 314.01, ADHD. What does “NOS”
stand for and what are the “Axis I-V” ? There is a 70 next to the Axis V. I can only find information on the main
diagnosis number of 314.01
A. NOS stands for “Not Otherwise Specified,” in other words,
a nonspecific form of some illness. She has been given the number 314.01, which is specific, so I assume the NOS was appended
to some other diagnosis. Axis I is major disorders (like ADHD) Axis II is for personality disorders and mental retardation
Axis III is for physical conditions like measles and broken arms Axis IV is for environmental conditions that might have an
effect on treatment, such as living in poverty or having no access to mental health care. Axis V is Global Assessment of Functioning,
which is a number (scale 1-90) that tells overall how well the person is functioning. 70 indicates very mild symptoms. Here
is a link to the Childrens’ GAF:
http://www.southalabama.edu/nursing/psynp/cgas.pdf
My book, DSM-IV
Made Easy, and the official DSM-IV both explain the axis system. You can also find a brief description of the axis system
at the following URL: http://allpsych.com/disorders/dsm.html
Why is the APA down on sharing criteria?
Q. Looking at your DSM-IV Resources site and my interest was piqued by
the quote:
“The American Psychiatric Association has
come down hard on any site that attempts to share criteria for DSM-IV disorders”
I’m just curious what the APA uses as a justification
for this given that the information is already in the public domain in the DSM anyway and in your published book. Is it particularly
websites delivering this information that they are concerned about? And if it is, surely all this does is disenfranchise those
without access to hardcopy libraries or the money to buy books? Not that I expect common sense from the APA. But I’d
love to know the arguments proposed.
A. There isn’t anything very extraordinary about the APA’s
approach. Their material is copyrighted and they intend to reap the benefits therefrom. That’s capitalism, for better
or for worse. I happen to have been caught up in the backwash, so I’m a bit unhappy about it. But I try to understand
the other side of the equation, too. When you think about it, the criteria are no more in the public domain than any other
copyrighted material -- the Encyclopedia Britannica, for example, or a movie on DVD. These materials cannot be passed around
freely, just because someone happens to want them without pay. I happen to believe there is something of a moral dilemma here,
inasmuch as on the criteria hang issues important for the health of individual patients the world over. That’s why I
do everything I can to help clinicians and patients understand the criteria, what they mean, how they should be used and interpreted.
But I am not allowed to promulgate them at the expense of their owners. BTW, you might take advantage of the Amazon.com “search
inside” feature, as I’ve noted on my page. It could help you out for a specific diagnosis.
Evolving definitions of PTSD
Q. Can you possibly forward to me all the definitions in the DSMs of
PTSD from DSMI to today? I really appreciate this. It is for a commutation case I am working on as a counselor, clinician.
Or refer me somewhere on the internet that might have it, thanks
A. This was quite an order, but here you are. You’ll have to piece
together the criteria -- I’ve only indicated where DSM-III-R differs from DSM-IV (saved me some typing time). If you
need that actual words written, you’ll probably have to go to a medical school library to find the older versions of
the DSMS.
[BTW, What’s a commutation case, and why are
the old definitions important?]
DSM-IV (this description is the paraphrase from my book)
A. The patient has experienced or witnessed or was
confronted with an unusually traumatic event that has both of these elements:
-The event involved actual or threatened death or
serious physical injury to the patient or to others, and
-The patient felt intense fear, horror or helplessness
B. The patient repeatedly relives the event in at
least 1 of these ways:
-Intrusive, distressing recollections (thoughts,
images)
-Repeated, distressing dreams
-Through flashbacks, hallucinations or illusions,
acts or feels as if the event were recurring (includes experiences that occur when intoxicated or awakening)
-Marked mental distress in reaction to internal
or external cues that symbolize or resemble the event.
-Physiological reactivity (such as rapid heart beat,
elevated blood pressure) in response to these cues
C. The patient repeatedly avoids the trauma-related
stimuli and has numbing of general responsiveness (absent before the traumatic event) as shown by 3 or more of:
-Tries to avoid thoughts, feelings or conversations
concerned with the event
-Tries to avoid activities, people or places that
recall the event
-Cannot recall an important feature of the event
-Marked loss of interest or participation in activities important to the patient
-Feels detached or isolated from other people -Restriction
in ability to love or feel other strong emotions
-Feels life will be brief or unfulfilled (lack of
marriage, job, children)
D. At least 2 of the following symptoms of hyperarousal
were not present before the traumatic event:
-Insomnia (initial or interval)
-Irritability
-Poor concentration
-Hypervigilance
-Increased startle response
E. The above symptoms have lasted longer than one
month.
F. These symptoms cause clinically important distress
or impair work, social or personal functioning.
Specify whether: Acute. Symptoms have lasted less
than 3 months Chronic. Symptoms have lasted 3 months or longer Specify if: With Delayed Onset. The symptoms did not appear
until at least 6 months after the event.
The differences in DSM-III-R:
A. The event is “outside the range of usual
human experience” and would be “markedly distressing to almost anyone.” There is no requirement that the
person feel fear, horror or helplessness
B. The patient relives the event repeatedly in one
or more of the ways mentioned in DSM-IV, except that physiological reactivity is not included.
C. The avoidance requirement is the same as DSM-IV.
D. Symptoms of increased arousal are the same, but
the physiological reactivity listed in DSM-IV is included here in DSM-III-R.
There is no requirement that the disturbance cause
significant distress or impairment in social, occupational, or other important areas of functioning.
The acute and chronic specifiers are not an option,
though delayed onset is.
The DSM-III criteria, in their entirety (though
slightly paraphrased):
A. Existence of a recognizable stressor that would
cause significant symptoms of distress in almost everyone.
B. Reexperiencing of the trauma in one or more of:
1) recurrent and intrusive recollections 2) recurrent dreams 3) sudden acting or feeling as if the traumatic event were reoccurring,
because of an association with an environmental or ideational stimulus
C. Numbing of responsiveness to or reduced involvement
with the external world, beginning some tie after the trauma, as shown by one or more of: 1) markedly diminished interest
in one ore more significant activities 2) feeling of detachment or estrangement from others 3) Constricted affect
D. At least 2 of these symptoms that were not present
before the trauma: 1) hyperalertness or increased startle 2) sleep disturbance 3) guilt about surviving when others have not
or about behavior required for survival 4) memory impairment or trouble concentrating 5) avoidance of activities that cause
recollection of the traumatic event 6) intensification of symptoms by exposure to events that symbolize or resemble the traumatic
event
[Unhappily, after all that typing, the person never
wrote back to give me details of what was being commuted.]
Funding for the DSM
Q. I am looking for information regarding the problems with DSM-IV manual.
Can you please explain how this information is formulated and by whom. Do you know who funds the diagnostic and statistical
manual? Can any big pharmaceutical companies be linked to funding? Any information would be very much appreciated
A. The information in DSM is compiled by committees that comprise psychologists
and psychiatrists from all over the world. They are mostly academics, and experts in the fields they work in. They use research
studies to determine the criteria for the conditions lists in the DSM. They are funded largely through the American Psychiatric
Association, and through sales of their publications, including DSM-IV. To my knowledge, there is no support from drug companies
or other commercial concerns, either large or small. I cannot say whether there is any support from charity or philanthropic
institutions—I just don’t know.
DSM-IV Additions
Q. I am doing a project at college and we have to find out what mental
disorders have been added to recent versions of the DSM. I would be truly thankful if you could help me out. Thank you.
A. Happily, you should have this information at your fingertips. Appendix
D of the official DSM-IV (not my book, DSM-IV Made Easy) lists all the changes from DSM-III-R.
Codes not in DSM-IV
Q. I am an officer with the U.S. Citizenship & Immigration Services,
under the Department of Homeland Security, and am reviewing a naturalization applicant’s medical diagnoses. A licensed
physician in the State of __ has stated that the individual in question has the following mental impairments: DSM-IV 290.0,
362.0, and 369.0. I have checked online resources, and find no information on DSM-IV codes 362.0 and 369.0. Do the latter
codes exist, and if so, what do they pertain to? Thank you for your time,
A. Your research is pretty good. That is, the 362 and 290 codes are not
for a mental disorder at all. Rather (if ICD-9-CM is the source, which I would suspect to be the case) they stand for:
362.0 Diabetic retinopathy
369.0 Profound vision impairment, both eyes
BTW, 290.0 is not a DSM-IV code as we would use
it in this country. Also an ICD-9-CM designation, it stand for “Uncomplicated senile dementia.”
Here is the web site for the ICD-9, in case you
have cause to refer to it later on:
http://www.cs.umu.se/~medinfo/ICD9.html
Does the DSM work for patients?
Q. Does the DSM work as a manual for giving patients diagnoses, or can
problems arise if a patient doesn’t completely fit a category?
A. This is a false dichotomy. Of course, there can always be problems
if you cannot make a firm diagnosis. However, the DSM is far better than what we used to have, so in general, it works well.
It allows the clinician to make predict such matters as: the best treatment, the need for insurance, the likelihood of recurrence,
the possibility of similar illness in close relatives. It also allows us to get parents, for example, off the hook by telling
them that a given illness (say, schizophrenia) is a genetically caused disorder, not one that comes about due to faulty child-rearing
techniques.
Learning DSM-IV
Q. Let me first introduce myself: I’m a psychologist in Europe, searching on internet for good information about
DSM-IV diagnosis. I found your site and information about books on this subject. As you possibly know, in [some countries
in Europe] it’s of growing
importance for psychologists to do a good diagnosis following the DSM-IV-criteria.
We even are obliged to fill in code-books with all the criteria. At this moment
I don’t feel equipped enough to do this, that’s to say I want to learn better! And that brings me to my question:
do you think your book offers me the right information or is it possibly too difficult to start
with in diagnosing? Here in [some European countries] we look at Dr. Phil, but I want a little bit more information about
my clients, a real good diagnosis. I would be grateful if you could give me some advice, in the way of books or otherwise.
I hope you can spare so time to react.
A. It is hard for me to be completely objective, because I think that
what I’ve written is pretty good. Here’s the best I can do: If you want to learn DSM-IV, you need a text. The
original DSM-IV (now it is DSM-IV-TR, which is just a little different from the original text issued in 1994) is pretty complicated,
and it includes no case illustrations. What I’ve written is something that tries to present the criteria and how to
use them, with a lot of case illustrations. A lot of people have found this book useful, and, if you get it, I hope you will,
too.
If you decide that you want the official DSM-IV-TR,
I would recommend that you also buy (or borrow) a copy of the DSM-IV Case Book. This is a separate publication that presents
a lot of case histories. These will help you understand what’s in the DSM-IV text. Also, if you have a case that is
puzzling to you, I’d be willing to read what you write about it and try to help point the way.
Same code numbers
Q. In DSM-IV, it seems to me that two different types of Attention-deficit/Hyperactivity
disorder have the same codes, i.e., 314.00 A-D/Hyperactivity Disorder Predominantly
Inattentive Type 314.01 A-D/Hyperactivity Disorder Combined Type 314.01 A-D/Hyperactivity Disorder Predominantly Hyperactive-impulsive Type.
Why is it that the last two, which appear to be different types of the disorder, have the same code numbers?
A. Strange, isn’t it, that the code numbers sometimes lag behind
the science.? The (very brief) introduction to Appendix F in DSM-IV-TR notes, “To maintain compatibility with ICD-9-CM,
some DSM-IV diagnoses share the same code numbers.” So there’s your answer: international compatibility.
DSM-IV limitations
Q. What are the limitations of using the DSM?
A. There are quite a few, of which I’ll mention several.
1) It conveys a sense of greater precision than
actually exists. There is still a considerable art to mental health diagnosis - - for example, a depression that should be
treated with medication (or cognitive behavior therapy) can be confused with a one that is secondary to drinking or drug use.
2) By reducing diagnosis to near-cookbook status,
it suggests that anyone can make a mental health diagnosis. The reality: it takes years of training and experience to create
a mental health diagnostician, and even then, we make mistakes.
3) Some diagnoses have complicated data sets (somatization
disorder is one of these) that render diagnosis cumbersome.
4) Clinicians often don’t use the manual;
this may mean that they follow the criteria “in principle” but not in detail, or it may mean that they ignore
it altogether.
5) On the other hand, some clinicians use it too
slavishly. It was designed as a guideline, not a straitjacket; if a patient almost meets criteria, perhaps that patient should
be included in a given category for treatment purposes (but not for research purposes). Confusing, isn’t it?
6) Not all the diagnostic categories have yet been
teased out. DSM-V, expected around 2012, may have some that have not yet been thought of, and may drop others. Such a fluid
environment means that we cannot be sure that patient will be regarded the same tomorrow as today.
Yet, I would emphasize that our situation now is
far better than when I was in training, a couple of generations ago. Then, diagnostic criteria were almost never used, and
clinicians made their determinations “by the seat of their pants (or skirts).” This worked to the disadvantage
of everyone, but especially patients.
???
5. Take for example, anorexia nervosa – the
DSM-IV suggests that a person has to be 15% under expected body weight and have amenorrhea for three consecutive cycles before
being diagnosed with anorexia nervosa. But women who are overweight often are diagnosed with Eating Disorder NOS, and others,
in less severe stages of the disorder, don’t display such symptoms. Could this lead to delayed treatment, or could mean
the disorder goes unrecognized?
I am sure that the use of NOS could delay treatment
at times. However, it may also forestall unnecessary or incorrect treatment. When used properly, NOS is a place-holder, followed
up as quickly as possible with laboratory inquiry or further interview or clinical observation, to determine more precisely
the correct diagnosis.
A patient who nearly meets criteria for, say, AN
is likely to be treated. However, if the weight loss as not been as severe as recommended in DSM-IV, that treatment program
might not include the more rigorous therapeutic maneuvers, such as involuntary hospitalization. In that sense, the NOS diagnosis
could work to the advantage of the patient.
Problems using NOS?
Q. Can NOS diagnoses cause problems for patients who need treatment?
A. I would answer as above, plus an anecdote. I saw a patient not long
ago who was depressed. He had been treated for major depression, but at some point a clinician had told him that he didn’t
meet the full criteria for major depressive disorder, and was therefore rediagnosed as NOS. This wasn’t necessarily
a mistake as regards the diagnosis itself, but the way it was presented to the patient caused consternation all ‘round.
I hope I’d have done it more tactfully.
Let me add that, whereas NOS can be a problem, it
is a necessary part of a package that has greatly facilitated mental health care over the past 25 years. Of course, the package
itself is defective, but I do believe that the mental health professions are making their very best efforts to improve diagnosis.
Clinician communication
Q. What should clinicians tell patients who receive a NOS diagnosis?
A. Mostly, clinicians communicate verbally with patients about diagnosis.
Thus, if I had a depressed patient for whom I wasn’t fully satisfied about the diagnosis (let’s say, due to 1C
above). I’d tell the patient that we cannot be sure of the exact cause of the clinical depression. I’d explain
the possibilities. It could the, for example, due to the fact that the patient has been drinking heavily for some time. I
wouldn’t ordinarily trot out the term NOS, but if it came up (the patient received an insurance form, for example),
I’d explain that NOS meant we had to spend a bit more time to be sure.
Right from the first, I would explore with the patient
the possible steps that we could take, and encourage the patient’s input. Through this process, I would expect that,
in the case of a patient with depression that might well be due to heavy drinking, we’d decide to treat the drinking
first, watch the depression carefully and only treat it if it didn’t rapidly clear up, once the acute effects of substance
use had been quelled. Understand, I would never lie to a patient; but I would couch my explanations in such language that
would minimize any anxiety about the diagnosis.
DSM revision process
Q. I apologize for the naiveté of my question, but I’m curious
how exactly a disorder becomes part of the DSM. (Does the task force meet every time a new edition is scheduled to come out
and say “Has anyone heard of this new disorder i.e. PMDD?”) I guess I’m curious to know about the process—someone
poses the idea of a disorder, they look in the literature for studies on it, and a task force meets? Thank you so very much for your help; I really appreciate it!
A. Here is a rough outline. Several years before a new DSM is released,
a task force is appointed by the American Psychiatric Association to review the old criteria, consider changes, and consider
any new additions to the document. The members of the task force are broken up into working groups, more or less along chapter
lines. The opinions of experts in a given field of study (including MDs, PhDs, and others) are solicited to get the benefit
of the best, most current thinking. In large part, the process is data driven—a
new disorder won’t be included unless there are data from a number of sources indicating that it is a “real”
entity and that it deserves to be included.
However, to be truthful, politics does enter into
the fray at times, and not all conditions are as well-studied as are, say, bipolar disorder and schizophrenia. Some disorders
that aren’t well-studied enough to include are put into an appendix with suggested criteria for further study. They
might be included in a later edition if enough evidence accumulates. (This was the fate of PMDD in DSM-IV). Sometimes names
of disorders are changed to make them more palatable to certain interest groups.
Before the DSMs
Q. What came before DSM-III? What’s different now?
A. The DSM has been around since 1952. That document, and its successor,
DSM-II, published in 1968, were just compendia of mental health diagnostic labels; they included no criteria. In effect, psychiatric
diagnosis was in chaos, with anyone free to make whatsoever diagnosis seemed appealing at the moment. OK, so I exaggerate,
but not by much. One famous study showed that American psychiatrists were far more likely to make the diagnosis of schizophrenia
than were British psychiatrists, who tended to diagnose mania or depression instead, in cases where there could be a question.
Here’s an illustration. Once when I was a
raw medical student, I spoke with a psychiatrist who told me about a young woman who had impulsively given away her car, worth
$500. “That’s schizophrenia,” the doctor assured me. This clinician wouldn’t be swayed by the argument
(especially from a mere medical student) that giving away something of value was more likely to suggest mania and manic-depressive
disorder.
A group of psychiatrists from Washington University in St. Louis published an article in 1972 that listed all the
diagnoses for which there were reliable studies supporting their validity as diagnoses. The same article included diagnostic
criteria for each of these diagnoses. From that beginning sprang the DSM-III, published to acclaim in 1980. Ever since, it’s
been a mad (you’ll excuse the term) race to better quantify criteria for these and other disorders.
In a nutshell, so to speak, what’s different
is that we now require criteria that have been proven by carefully controlled studies to define diagnoses that allow us to
make the sort of predictions that clinicians (and patients, too) rely on. (I’ve mentioned those predictions in my earlier
e-mail.)
Further evolution of the DSM
Q. What do you see the DSM system of diagnosis evolving into?
A. The broad answer to this question is, I don’t see it changing
radically. I think that, in general, we’ll more carefully define existing criteria and tease out still more diagnoses
than now exist—but mainly those that have been studied well enough that we can be confident where we stand scientifically.
A few will be dropped (not everything in the manual right now has equal scientific backing). And there may be a change in
the case of some diagnoses, notably the personality disorders, from categorical criteria (that is, you count the number of
symptoms) to dimensional (whereby you measure something, as with a scale). The problem with the categorical system is that,
with 10 currently accepted personality disorders, too many patients have features of more than one. You then face the choice
of diagnosing more than one, and sometimes 3 or 4, Axis II conditions for a single patient, which hardly carves nature at
its joints, or trying to get clinicians to administer scalar measuring instruments to every patient they see. A conundrum.
Homosexuality and the DSM
Q. I believe the earlier edition of the DSM still
considered homosexuality to be a mental disorder. What year did the DSM IV first appear?
A. The DSM-III, published in 1980, did include the
category “egodystonic homosexuality.” This category was removed from the 1987 DSM-III-R. DSM-IV, published in
1994, doesn’t even mention it in the index.
Other, general questions about the field of mental health
Ideas of reference
Q. I am a graduate of Counseling Psychology (M.A.) working toward my M.F.T.
(California). My question: What is meant by “ideas of reference,”
as in the first criterion for diagnosing Schizotypal Personality Disorder?
A. Ideas of reference is when a person hears or reads something that is meant
generally, but applies it to him/herself personally. For example, if you heard a radio broadcast about a battle plan and thought
it meant that you should fight it out with your neighbor about the fence he is building. Other persons with ideas of reference
might similarly misinterpret what they read or see on TV. (Commercial announcement: This stuff is covered in my book, The
First Interview, by the way, and also in DSM-IV Made Easy.)
Diagnosis of stockpiling
Q. I was wondering if you would be able to help me out with a DSM diagnosis
for my abnormal psychology class. The definition of the diagnosis is: the abnormal pattern of stockpiling goods in anticipation
of doomsday. I would appreciate any help you could offer!
A. Well, you aren’t going to be able to make an actual diagnosis
based on such skimpy evidence. What you can do is create a differential diagnosis—a list of possibilities that would
fit with the symptom you mention. Is differential diagnosis something that you’ve studied about?
That said, here’s the sort of thinking I’d
do:
Saving of stuff is a criterion of Obsessive-Compulsive
Personality Disorder, so that would go on the list. Of course, any time you consider Obsessive-Compulsive Personality Disorder,
you’d better also mention plain old Obsessive Compulsive Disorder, too.
I’d also wonder whether this person has a
depression, either major depressive disorder or bipolar depression (gloomy predictions about the future are commonplace in
mood disorders).
I’d at least mention the possibility of a
psychotic disorder, though my heart isn’t really in it. But I’d want to know (by means of an interview) whether
the person had a delusional idea that the end of the world is at hand.
Finally, or perhaps first (because it is important
ALWAYS to consider this sort of thing) I’d consider whether the person could have a medical problem (tumors, endocrine
disease) that could be producing such a funny mental symptom, or perhaps a substance use problem. Just about anything can
happen with a substance use problem such as alcoholism.
Finding a study
Q1. I am with ___ news and I am trying to track
down a study in which the same paper was given to professors to grade, sometimes with a male name, sometimes with a female
name. The study showed that those with male names got higher scores even though the papers with female names were identical.
A. Sorry, but I don’t have this information.
I looked a little on line to see whether it floated immediately to the top of the pile, so to speak, but it didn’t.
Here’s how I would proceed: Use Medline (URL
below), and search for recent papers on the subject of gender bias. Find a professor who has written about similar subjects,
go to the university’s website, and search the faculty page for the professor’s email address. Whew. Then, email
that person, who will have a much better chance of being able to help you out. Hope this helps.
A2. I apologize for the late reply. But your advice
was good and it garnered a few results. Thank you for your help!
Child medication combination
Q. A 6year-old child is on Ritalin and Abilify. This concerns me and
I’m unable to find any research on the combination of these meds or the use of this antipsychotic with pediatric clients.
Is this safe and or appropriate for a six year old?
A. I’m going to have to disappoint you on this one. I am not a
child psychiatrist, and I have no special expertise in drugs for children. I would not be doing you a service by giving an
opinion on this question. You could look on Medline to see whether articles have been written about this subject. The URL
is:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi
You can then enter the subjects you are interested
in and click “go” to find articles that might help you.
Thesis topic
Q. I am writing concerning possible help or information which I thought
you would be highly suited/credited to provide for a thesis I am required to write in my senior year of high school. I am
participating in the International Baccalaureate program, which is additional diploma to the high school diploma that attempts
to provide a world-wide curriculum for those who pursue its rigor. In order to be eligible for this diploma students must
complete what is called an Extended Essay, which is a 4,000 word maximum essay on the topic of our choice. I have become very
interested in the field of psychology after my junior year introductory course to psychology, IB Psychology SL.I have chosen
to write my essay on the influx of the diagnosis of Attention Deficit/Hyperactive Disorder in the United States in the last
decade. My position on the paper is to conclude that ADHD has been misdiagnosed as well as over diagnosed in the United States and that the we should
take caution when prescribing drug treatment as the first line of treatment. I admit I have been very lax in beginning this
essay and its final draft is due [in one month]. However, much of the information I am using comes from either the DSM- IV,
or reputable sources which reference the DSM-IV for their information. I would highly appreciate any information you could
possibly provide to me on the limitations of the DSM-IV and/or strengths of following such a manual. I am aware that the DSM-IV
is not a world wide reference for the field of psychology, and would like to include the lack of the inclusion of ADHD of
the diagnostic systems of the International Classification of diseases published by the World Health Organization for which
many European professionals tend to use. My current position is not that ADHD does not exist, because given the quantitative
data that has been gathered in recent years, its existence is evident to me. However, I am under the impression that it is
highly probable that currently many children are being diagnosed with ADHD when their behaviors represent simple immaturity,
as well as many other factors which are part of childhood and development. Also, I think that the use of stimulant drugs,
given that only approx. 50% of those diagnosed with ADHD are effectively treated by such drugs, as a first line of treatment
is overly trusted and possibly detrimental to the future of our American society. I am curious if you have an opinion on the
subject, even if it is completely different from my own, given that your credentials and knowledge of this topic may be much
greater than my own. This is the reason for my writing of this essay. I wish to learn more of the field of psychology and
include myself in the widely varied opinions supported by the field of psychology. Thank you for reading this elongated email,
and I hope to hear back from you on this topic, even if you feel as if you cannot help me or provide me with information.
A. Alas, your project bears the seeds of its own destruction, in that,
whereas you profess to seek the truth about a subject, you have already formulated your conclusion. This is not what psychology
is all about. Nonetheless, I’ll try to give you my perspective on ADHD and the DSMs.
It is undeniable that ADHD has been misdiagnosed
in the past, and it probably still is, in some quarters. However, with criteria derived from myriad scientific studies, DSM-IV
provides the tools to reduce misdiagnosis substantially. (BTW, your perspective is too narrow: people were complaining about
the burgeoning diagnosis of ADHD well before you were born.)
I, too, worry about prescribing medication when
it is not needed, and that includes many disorders other than ADHD. However, studies continue to demonstrate that for a child
who does have ADHD, stimulant medication provides the most effective method of help. As to whether there are many children
who are simply immature, rather than suffering from ADHD, that is a subject that could be tested empirically; without data,
it is not a best dealt with by polemics.
May I add a few words of criticism, on a more personal
level, that I hope you will accept as constructive? Your letter is replete with long words and locutions, where shorter words
and simpler syntax would work better. I learned long ago (though, I confess, way
later than my senior year in high school!) that the job of any writer is to communicate effectively with the largest audience
possible. That means, write in clear, simple prose that can be understood by persons who may not have attained even your current
level of education.
Serial Killers
Q. I attend __ High School where I am currently taking an introductory
course in psychology. Recently my teacher assigned a project to the class as a “midterm” assignment. This assignment
consists of that of a research project, where we are to choose something that interests us in the Psychology field and find
out about it. I have always been interested in the criminal mind and hope to one day find a career in analyzing the minds
of criminals. For my project I have decided to find the development, causes and characteristics of a criminal mind, more directly
on the mind of a serial killer. I have done some minor research in the past for a Russian history class, in which I only scratched
the surface enough to understand what a serial killer was so that I could “visualize” the actions that Russian
Czar “Ivan the Terrible” took during his reign of power. I’m not sure what I am trying to ask of you, but
I was wondering if you could tell me where to get started on my research. I believe that I am going to focus on the causes
and mental development as well as the characteristics that make a serial killer a serial killer. Thank you so much.
A. I’m not sure that I can provide all the help you need here.
I’m a general psychiatrist, not a forensic one, so I don’t have a lot of specialized information at hand. However,
here is a URL that provides the histories of a number of serial killers. You’ll have to see what information this site
may provide about state of mind, but at least you can get some of the basic background. It certainly is interesting.
http://www.crimelibrary.com/index.html
What you’ll probably need in addition is one
of the major texts on forensic psychiatry. One is by Slovenko: Psychiatry and Criminal Culpability; another is Simon: Clinical
Psychiatry and the Law. There are also others. A much older book, one that talks about the “classic sociopath,”
is The Mask of Sanity, by Hervey Cleckley. Most any library should have it.
Straightforward treatment?
Q. If an accurate DSM-IV diagnosis is made, is treatment straightforward?
A. Nothing is ever straightforward. Assuming you make the correct diagnosis,
for most disorders there is a whole range of possible treatments. In some cases, one has been proven more effective than another,
but often it is a matter of the patient’s own circumstances, physical and emotional constitution, and so forth. You
can read more about this issue in such books as my “Straight Talk About Your Mental Health.”
What is R/O?
Q. I am a grad student and for the life of me I can’t find a definition
for what it meant when something reads “R/O PTSD” or “R/O Bipolar”? Can anyone help on this simple
but for me puzzling definition?
A. R/O is the time-honored abbreviation for “rule out.” I
can remember being puzzled at its definition when I was a student. What it means is this: by further investigation (history,
lab tests, psychological evaluation) the following diagnosis needs to be excluded. It is a statement of doubt, and one that
should never appear as the final diagnosis. It is a usage sanctioned by neither the DSMs nor, to my knowledge, the International
Classification of Disease, but it has been with us forever and will, I am sure, remain long after we are gone.
Graduate Psychology Programs
Q. I was looking over your site and read some of the Q&A. I have
a question for you about graduate work in psychology. I want to get a degree and I’m unsure about whether to go for
the Psy.D. or Ph.D. What are the setbacks of just having a Psy.D. rather than a Ph.D. in the career field? I’ve found
programs and really liked their Social Psych, and wanted to go into that rather than their clinical, but then the social program
says nothing about accreditation. Does the APA just accredit counseling and clinical programs? I’ve been told a degree
that isn’t accredited won’t be worth anything, so if I were to get a doctorate in social psychology that wasn’t
APA accredited would it be worthless? I’m confused!
A. I’ll have to refer you on for this question. I’m a psychiatrist
(MD), and I don’t have special knowledge about psychology programs. I can tell you that, generally, people who obtain
Psy D degrees are more interested in practice, whereas the Ph D programs are often more tilted toward research. If your interest
is in research and teaching, the latter might be better tailored for you. I would find a few psychologists with each degree
and talk to them. I just now Googled “Psy D programs” and got the URL just below. It looks as though it contains
some resources that might help you. There were half a million other hits, so you might try the same trick yourself.
http://www.lemoyne.edu/OTRP/otrpresources/psyd/psyd.html
Definition of mental disorder
Q. I think I know what mental disorder means but could you give me a
‘keep it simple, stupid’ definition? Also, do you think the medical community generally considers depression to
be a ‘mental disorder’? Even what someone might call situational depression?
A. Here is my (simple) paraphrase of DSM-IV-TR’s definition: A
mental disorder is a clinically important collection of behavioral or psychological symptoms that causes an individual distress,
disability, or the increased risk of suffering pain, disability, death, or the loss of freedom.
I really cannot speak for the medical community
in general, but I THINK that most physicians would consider major depressive disorder to be a mental disorder. As to a situation
depression, it would depend on the severity. One that is relatively mild and not too long-lived even I might not consider
to be a mental disorder. Hope this helps.
Harry Stack Sullivan and Interviewing
Q1. I read The Psychiatric Interview
by Harry Stack Sullivan. How does it differ from your book, The First Interview?
He conducted Interpersonal psychoanalysis. Is this not the same procedure you discuss in The
First Interview? I really don’t understand the advantages versus the disadvantages between the two styles. Can you
clear this up for me.
A1. In brief, Sullivan’s book covers much the same ground, but
relies wholly on his own view of psychiatry, whereas mine is based on as much scientific study as had been done up to the
time of writing. Sullivan tends not to use examples, whereas I do. And I think that mine (as well as other interview books
that have been written since Sullivan’s) is a good deal more encyclopedic in terms of the variety of issues to cover
and pathologies to note. I think Sullivan’s work was good for its time; its time has passed, however.
In short, as a beginning student in counseling,
you need more information about diagnosis and interviewing that HSS can give you.
Q2. Thank you for the quick response. One final question. How do you
view psychiatric disorders in comparison to Sullivan’s view?
A2. First, I am not a Sullivanian, nor do I really know that much about
HSS. So you will find people far better qualified to speak than I.
However, I do know that he lived and wrote at a
time remote enough from ours that he knew little of modern ideas concerning genetic inheritance and its place in the development
of mental disease; he primarily wrote about social and psychological theories of the development of disease. He was not much
of a researcher, to the best of my knowledge; like Freud, he wrote from what he had experienced, and not from statistically
tested data sets. He rejected the importance of diagnosis, which is one of the main differences between him and most modern-day
clinicians. And it is that rejection that makes him, in my opinion, largely irrelevant today.
Insanity
Q. I have a two part question. What are the standards, with respect to
which one is determined to be insane? 1.) For legal purposes and 2.) For psychiatric or psychological purposes. Are there
specific or categorical beliefs, (on the part of the person in question) that could be depended on to establish one’s
insanity? I’ve been told that the world of psychology no longer uses the term. It seems that the law would require that
or an equivalent term.
A. The term “insanity” is one that has no scientific definition;
we don’t use it in making diagnoses in mental health circles. As a legal construct, it is a very big subject. There
are at least 4 different definitions in use in the legal world. Rather than try to summarize, I’ve provided a link to
a website that will help you understand.
http://law.enotes.com/everyday-law-encyclopedia/89917
Is it schizophrenia?
