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Dr. Bob is Robert Hsiung, MD,
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Posted by notfred on May 15, 2006, at 16:20:35
In reply to new diagnostic manual, posted by pseudoname on May 15, 2006, at 15:24:20
Haveing a specific diagnosis does not improve outcome or treatment. DSM or PSM just codes things
so someone can get paid.j
Posted by pseudoname on May 15, 2006, at 16:34:44
In reply to Re: new diagnostic manual, posted by notfred on May 15, 2006, at 16:20:35
> Having a specific diagnosis does not improve outcome or treatment.
That's for sure. But part of my point is that these little codes are pernicious. The clinical, interpersonal relationship is *worse* because of them.
Posted by notfred on May 15, 2006, at 18:32:08
In reply to new diagnostic manual, posted by pseudoname on May 15, 2006, at 15:24:20
Personally, I think EFFECTIVE diagnostic categories — ones that point to specifically effective treatments — might someday be based on brain scans and genetic testing, in addition to in-life observations (like in the home) and today's history-style interviews. But we're not there yet.
& prior to the DSM, no 2 doc's had the same criteria for any Dx. Depression had different signs and symptoms amoung different doc's.
That is the big change DSM brought about;
a level playing field.I do not see how DSM effects or enters into treatment (other that getting someone paid)
as pdocs are treating symptoms and making med choices not based on specific meds for your condition but what you can tolerate. And psyco meds tend to be non-specific; one med is useful
for many different kinds or mental illness.
Posted by Declan on May 15, 2006, at 18:54:05
In reply to new diagnostic manual, posted by pseudoname on May 15, 2006, at 15:24:20
There was a shrink who told me maybe I had NPD. Depressed/depleted narcissistic personality disorder. Hmmmm. I'll have to look it up...thanks for the link.
Posted by Phillipa on May 15, 2006, at 20:03:11
In reply to Re: new diagnostic manual, posted by notfred on May 15, 2006, at 18:32:08
Agree. Love Phillipa
Posted by Caedmon on May 15, 2006, at 22:37:43
In reply to Re: new diagnostic manual » notfred, posted by Phillipa on May 15, 2006, at 20:03:11
I believe that DSM categories were originally designed to help keep research definitions consistent. They *weren't* necessarily designed as methods to diagnose disorders, let alone the whole spectra of the human condition.
I guess I don't see what the big deal is.
- Chris
Posted by Emily Elizabeth on May 15, 2006, at 22:38:23
In reply to new diagnostic manual, posted by pseudoname on May 15, 2006, at 15:24:20
I did not read all of this thread, but I wanted to jump in that my understanding of this psychodynamic manual is that it is intended more to help guide psychological treatments rather than psychiatric ones. I only skimmed a draft of one of the chapters, but the psychologist who was telling me about it was pretty enthusiastic that it provided a theoretically grounded alternative to the DSM's atheoretical cluster of sx approach.
Regardless, I would like to add that it is a tool like the DSM and that any tool is only as good as the person using it. Even if some of the suggested terms sound more pejorative (a consistent short-coming of the psychodynamic/analytic crowd) they can be applied in a warm empathic way by a good clinician.
Best,
EE
Posted by Larry Hoover on May 15, 2006, at 22:51:12
In reply to Re: codes are bad » notfred, posted by pseudoname on May 15, 2006, at 16:34:44
> > Having a specific diagnosis does not improve outcome or treatment.
>
> That's for sure. But part of my point is that these little codes are pernicious. The clinical, interpersonal relationship is *worse* because of them.I certainly agree with you both.
Patient presents with sx (symptoms).
Doctor does magic integration and labels dx (diagnosis).
Doctor infers from dx the appropriate tx (treatment).
Doctor fails to check and see if all sx get any better, or if tx makes new sx, because he's too busy txing a dx.Lar
Posted by pseudoname on May 15, 2006, at 22:52:07
In reply to Re: new diagnostic manual » pseudoname, posted by Declan on May 15, 2006, at 18:54:05
> There was a shrink who told me maybe I had NPD.
Narcissistic? Declan? I've never met you, but I'm surprised at such a diagnosis, based on our encounters here.
I was just now reading about this stuff. It's the whole depression-is-aggression-turned-inward hokum. The narcissist is depressed because people aren't worshipping him like they used to.
Maybe you challenged something the shrink said; he felt threatened because you seemed smarter than he was. They keep NPD ready for situations like that.
These diagnoses serve more functions than just getting insurance checks.
Posted by pseudoname on May 15, 2006, at 23:58:44
In reply to Re: new diagnostic manual, posted by Caedmon on May 15, 2006, at 22:37:43
Chris,
Have I offended you in some way? This is the second post by me in two weeks to which your response has been, “I don't see what the big deal is.”
Last time I bit my tongue. This time I'll make some "I"-statements.
Not everything I post about is a big deal. I'll admit that at least 99% of my posts are NOT a big deal. Virtually anything I post can easily be dismissed by any other human being. Of course, perhaps it's good to have that actually keep happening just to make sure I'm properly oriented.
> I believe that DSM categories were originally designed to help keep research definitions consistent.
Nope. Diagnostic agreement among psychiatrists was running as low as 32% in pre-DSM days. The DSM was created to try to make psychiatric diagnoses consistent clinician to clinician (scientifically “reliable”) because, as an early DSM editor said, “without reliability the system is completely random, and the diagnoses mean almost nothing — maybe worse than nothing, because they’re falsely labelling. You’re better off not having a diagnostic system.”
So they made the DSM to try to prove to the critics that the diagnoses psychiatrists were already making were somehow not false. The DSM thus tried, and only partly succeeded, to fix the “reliability” problems.
The validity problems are an open issue.
Alix Spiegel wrote a history of the DSM in the Jan 3 '05 New Yorker, which was discussed here at the time: http://www.dr-bob.org/babble/psycho/20041218/msgs/434588.html (Note: Also not a big deal.)
> They *weren't* necessarily designed as methods to diagnose disorders
That is exactly what they were explicitly designed to do. Their additional use in research (which was a secondary intention) couldn't possibly change that. How would research using such criteria ever be clinically applicable if practitioners weren't also using them?
And anyway, even had it been otherwise originally, the DSM IS USED THAT WAY NOW. Are you saying it should not be? Welcome to the club. (But be prepared for people to tell you they don't see what the big deal is.)
> let alone the whole spectra of the human condition
I don't know what you mean.
Posted by pseudoname on May 16, 2006, at 0:56:30
In reply to Re: new diagnostic manual, posted by Emily Elizabeth on May 15, 2006, at 22:38:23
Hi EE. Always nice to read your take.
I should probably make clear that I'm not reflexively hostile about this topic. (Or at least take care that I'm not.)
Interesting to hear how some clinicians are responding to the PDM. A lot of people are very tired of the DSM. “Atheoretic” is the nicest way of describing it.
I read a couple years ago that psychologists (not this psychodynamic group) were talking about coming out with their own diagnostic book, but I don't think it went anywhere. The feeling was that it could never compete with the DSM. But maybe if the PDM does well, that one and even others might spring up, too. More choice in this area sounds like a good thing to me.
> I would like to add that it is a tool like the DSM and that any tool is only as good as the person using it.
You're right, a good tool can be used badly. But perhaps we disagree on these manuals being good tools at all. Telling someone she has a histrionic personality disorder could be done compassionately and with sensitivity — AND be unhelpful and invalid. If it does not in any significant way channel the treatment, what purpose does such a loaded, stigmatizing differential diagnosis perform, no matter how it is conveyed to the patient?
Or does it help? I guess I haven't seen that spelled out.
EE, would the DSM or the PDM help you as a clinician? Maybe I should try to see the issue from that angle.
–PN
Posted by notfred on May 16, 2006, at 9:15:02
In reply to good tool » Emily Elizabeth, posted by pseudoname on May 16, 2006, at 0:56:30
> You're right, a good tool can be used badly. But perhaps we disagree on these manuals being good tools at all. Telling someone she has a histrionic personality disorder could be done compassionately and with sensitivity — AND be unhelpful and invalid. If it does not in any significant way channel the treatment, what purpose does such a loaded, stigmatizing differential diagnosis perform, no matter how it is conveyed to the patient?
How does the DSM have any bearing on how a pdoc talks to patients ? It is a medical text, written in clinical style. It is not 1) for patients or 2) to be read to patients.
>
> Or does it help? I guess I haven't seen that spelled out.
>
> EE, would the DSM or the PDM help you as a clinician? Maybe I should try to see the issue from that angle.
>
> –PN
Posted by notfred on May 16, 2006, at 9:17:10
In reply to Re: codes are bad » pseudoname, posted by Larry Hoover on May 15, 2006, at 22:51:12
> Patient presents with sx (symptoms).
> Doctor does magic integration and labels dx (diagnosis).
> Doctor infers from dx the appropriate tx (treatment).
> Doctor fails to check and see if all sx get any better, or if tx makes new sx, because he's too busy txing a dx.
>
> Lar
Given that doc's tell me dx does not matter, I do not see my docs spending much time on a dx.j
Posted by pseudoname on May 16, 2006, at 12:05:25
In reply to Re: good tool, posted by notfred on May 16, 2006, at 9:15:02
J,
> How does the DSM have any bearing on how a pdoc talks to patients ? It is a medical text, written in clinical style.
> It is not 1) for patients or 2) to be read to patients.I really don't know how to respond to that. You apparently have a very different reading of my post, and this thread, than I do.
> Given that doc's tell me dx does not matter, I do not see my docs spending much time on a dx.
It sounds from this and your earlier post like your doc has a good attitude toward psych diagnoses. Some do, and I wish that it were more widespread.
But we can't generalize from our individual experience with a few good (or bad) clinicians to the entire domain of the DSM's influence in the world.
The unfortunate fact is that many clinicians, especially those in managerial, legal, academic, research, and other influential positions, take the DSM and its minute details of diagnosis very seriously. That fact should be obvious from the tremendous energy put into this gigantic, expensive book's constant expansion and revision. As the New Yorker made clear, seats on the DSM board are highly coveted positions that prominent professionals devote part of their careers in hope of getting.
> I do not see how DSM effects or enters into treatment (other that getting someone paid)
Clients are exposed to their own diagnoses all the time; sometimes, sharing that is a part of treatment. Furthermore, studies have shown that practitioners are influenced in their own evaluation of people by the diagnoses listed on the patients' files. (Similar studies have shown such bias in teachers exposed to their students' diagnoses.)
Graduate schools in psychology sometimes organize their clinical classes explicitly around the DSM numbers! Forensic psychiatrists and probate-type judges make decisions about people's freedom based entirely on the DSM checklists.
J, if it were up to your pdoc (and mine), we'd replace the whole thing with something more pragmatic and less dangerous.
But that's not the case. We shouldn't dismiss an entire issue based only on our limited personal experience.
Posted by naughtypuppy on May 16, 2006, at 12:39:13
In reply to dismissing the issue » notfred, posted by pseudoname on May 16, 2006, at 12:05:25
I think my doctor has the right attitude for DSM diagnosis. It's just a shorthand language that doctors use at conventions to make sure that their on the same page. There is really too much overlap for them to be really useful.
Posted by notfred on May 16, 2006, at 13:00:25
In reply to dismissing the issue » notfred, posted by pseudoname on May 16, 2006, at 12:05:25
But we can't generalize from our individual experience with a few good (or bad) clinicians to the entire domain of the DSM's influence in the world.
I would say the same is true for your statements.
Posted by Caedmon on May 16, 2006, at 18:52:46
In reply to big deal » Caedmon, posted by pseudoname on May 15, 2006, at 23:58:44
> Have I offended you in some way? This is the second post by me in two weeks to which your response has been, “I don't see what the big deal is.”>
No - what I meant by that was, I don't see the "big deal" on the part of creators, about creating an alternate diagnostic manual. I don't understand why the clinicians who created the PDM (sic?) felt that what they were doing was all that unique, or why they felt it would contribute to their field in some way. I got the impression that it's just as arbitrary as the DSM. So it's not really that unique, hence not a "big deal". Hope that makes sense.
> > They *weren't* necessarily designed as methods to diagnose disorders
>
> That is exactly what they were explicitly designed to do. Their additional use in research (which was a secondary intention) couldn't possibly change that. How would research using such criteria ever be clinically applicable if practitioners weren't also using them?>That wasn't my understanding. Maybe I read something wrong at some point.
- Chris
Posted by Declan on May 16, 2006, at 21:52:15
In reply to Re: dismissing the issue, posted by notfred on May 16, 2006, at 13:00:25
I would rather that the input for a DSM type thing NOT come from an English speaking country; maybe even from India, or Russia, preferrably Kirghizstan, Armenia or Bhutan. Noone will take this seriously, but I don't want to take my ideas about mental health from (sub)urban academics, even if I do get to call myself a depleted narcissist.
Posted by ed_uk on May 17, 2006, at 9:13:02
In reply to Re: dismissing the issue, posted by Declan on May 16, 2006, at 21:52:15
Hi Dec
Perhaps I should write a DSM? Would you like your very own syndrome? :)
Ed
Posted by Larry Hoover on May 17, 2006, at 9:25:00
In reply to Re: dismissing the issue » Declan, posted by ed_uk on May 17, 2006, at 9:13:02
> Hi Dec
>
> Perhaps I should write a DSM? Would you like your very own syndrome? :)
>
> EdYou know what, Ed? I think that's the problem, in a nutshell. We all have our very own syndromes in the first place.
Lar
Posted by ed_uk on May 17, 2006, at 9:30:25
In reply to Re: dismissing the issue » ed_uk, posted by Larry Hoover on May 17, 2006, at 9:25:00
Hi Lar
>We all have our very own syndromes in the first place.
I do. A lot of people don't fit 'neatly' into any DSM categories. The more you learn about someone's individual problems, the less their diagnosis seems appropriate.
Ed
Posted by ed_uk on May 17, 2006, at 9:30:57
In reply to Re: dismissing the issue, posted by ed_uk on May 17, 2006, at 9:30:25
Posted by pseudoname on May 17, 2006, at 9:38:44
In reply to Re: dismissing the issue » Declan, posted by ed_uk on May 17, 2006, at 9:13:02
> Perhaps I should write a DSM? Would you like your very own syndrome?
May I suggest…
734.1(a) declanania.
Rare. Characterized by wide reading and subtle, thoughtful observation. Celebrated in some online subcultures.
;-)
Posted by Larry Hoover on May 17, 2006, at 9:58:33
In reply to declanania » ed_uk, posted by pseudoname on May 17, 2006, at 9:38:44
> > Perhaps I should write a DSM? Would you like your very own syndrome?
>
> May I suggest…
>
> 734.1(a) declanania.
> Rare. Characterized by wide reading and subtle, thoughtful observation. Celebrated in some online subcultures.
> ;-)Awwwww. That was nice.
Lar
Posted by ed_uk on May 17, 2006, at 11:33:58
In reply to declanania » ed_uk, posted by pseudoname on May 17, 2006, at 9:38:44
I love it!
Ed
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