Challenges of Psychiatry Blogging: Why Start? Why a Pseudonym?

This is part 4 of my series on the challenges of psychiatry blogging. Previous posts covered content, audience, and design.

Why Start?

I'm sure everyone who blogs does so for intensely personal reasons; thus, I will not speculate on anyone's motivations but my own here. I've always enjoyed writing but have not done much of it since college. I enjoy reading other psychiatry and neuroscience-related blogs, and I've long wished that there were more blogs focused on the many important issues related to child psychiatry. Eventually, I decided to start a blog myself for that niche. I hope to be critical in the sense of "involving skillful judgment as to truth, merit, etc.; judicial," rather than being "inclined to find fault or to judge with severity, often too readily." Though I've focused a lot on the DSM thus far, it is no accident that my first post was a movie review, and I hope to write about a broad range of topics, including vignettes from my own clinical experiences.

Why Now?

Why did I choose to start the blog last month, instead of at some other time? This question is harder to answer, and so let me examine it as I would any complex human behavior. Could it be that some life change increased the free time I have? Could I have been inspired by reading other blogs and being caught up in the zeitgeist with the DSM-5 about to be released? Is it that I finished writing a self-reflective piece offline, and encouraged by how rewarding it felt, managed to overcome previous inertia? Does it have anything to do with the fact that, after having knee pain for the last few years, I finally found a way to deal with the pain in April, thus allowing me to run again (and I'm getting good ideas while running)? Could it be the increased daylight and seasonal change helped me be more alert and focused? Is it that I've been drinking stronger coffee? I can't give you a simple explanation for why now, except to say it's likely a combination of several of those factors.

The Name Thing

Why am I using a pseudonym instead of my real name? Well, first let me say it's not so that I can vent my frustrations or write mean things. I'm more likely to use profanity in real life than on this blog. I'm fully aware that there is no true anonymity on the Internet, so I write everything as if it were under my actual name. I treat a blog post like I would an essay, refining each one until I am somewhat satisfied with the result.

Neuroskeptic has actually written a paper on the topic of anonymity in science, and how it can "facilitate the free expression of interpretations and ideas, and can help to ensure that suggestions and criticisms are evaluated dispassionately, regardless of their source." I'd like to think that's one of the main reasons why I use a pseudonym. Another reason is simply convenience. It's much easier for someone to Google "psycritic" to look up my blog (as well as my comments on other blogs), than to search for a name that belongs to many people. It helps me compartmentalize; though my patients are unlikely to bring up this obscure blog, I would still prefer to not have to chat about the blog during our sessions, and instead focus on what is going on in their lives.

Lastly, we come to the name itself. Why Psycritic? Well, as I said on Twitter:

Hoping to have a productive time blogging, emulating @neuro_skeptic & @neurocritic, with an emphasis on child & adolescent psychiatry.
— Psycritic (@psycrit) April 28, 2013

What can I say? It's certainly not original, but the domain name was available. Now, we just need a psychskeptic who blogs, and we'll have a complete tetrarchy!

What If the NIMH Succeeds? What Then?

Ever since National Institute of Mental Health (NIMH) Director Thomas Insel wrote his Transforming Diagnosis article on how the NIMH is moving away from the DSM to a new system called the Research Domain Criteria (RDoC) for future research studies, there have been countless articles and blog posts written about what this may mean for the future of mental health.

One of the most insightful perspectives comes from 1 Boring Old Man, who points out that the NIMH is trying to do the same thing as the DSM-5 all over again by focusing on "biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms" [quote is from the NYTimes article]. Dr. Allen Frances, the Chair of DSM-IV, thinks the new NIMH approach has merit, but he strongly criticized the NIMH for over-promising advances that won't arrive for a very long time, while ignoring the present plight of the chronically mentally ill.

Neuroskeptic likened the controversy to the Protestant Reformation, with the NIMH's RDoC (Protestantism) rising to rival the DSM approach (Catholicism), but in the end they worship the same God (biological psychiatry). This focus on the biological basis of mental illness troubles me, since I think it is terribly limiting. So much of a person's well-being is dependent on relational aspects and influenced by culture and society, as the Child in Mind blog pointed out. According to NIMH's mission statement:

The mission of NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure. For the Institute to continue fulfilling this vital public health mission, it must foster innovative thinking and ensure that a full array of novel scientific perspectives are used to further discovery in the evolving science of brain, behavior, and experience. In this way, breakthroughs in science can become breakthroughs for all people with mental illnesses.

Though this statement does not explicitly constrain the NIMH to only fund studies looking at the biological aspects of mental illness, the language of "curing" someone obviously reflects a biological perspective. Dr. Insel is a quite a True Believer in the premises behind biological psychiatry, as shown in his TEDxCaltech talk:

“If we waited for the ‘heart attack,’ we would be sacrificing 1.1 million lives every year in this country,” he said. “That is precisely what we do today when we decide that everyone with one of these brain disorders, brain circuit disorders, has a behavior disorder. We wait until the behavior emerges. That’s not early detection, that’s not early prevention.”

As ridiculous as the above position sounds to me, let me play devil's advocate and future-think. Suppose the NIMH succeeds beyond anyone's—even Dr. Insel's—wildest dreams. What if their biological paradigm is able to elucidate at the brain circuit level (including all the circuits for positive/negative emotional valence, cognition, social processes, and attention/arousal) exactly what is happening when a person is depressed, or anxious, or hallucinating, and technology advances enough so that treatments can directly target those dysfunctional brain circuits, what then?

Well first, to make the diagnosis, there will have to be some kind of brain imaging examining the circuitry, likely coupled with obtaining a person's genetic profile. Given the complicated wiring in the brain, this will have to be done by a computer instead of a human. Treatments clearly won't be like today's medications that just target a receptor or set of receptors. To target a circuit, I can envision several methods: 1) The circuit would either have to be ablated using precise neurosurgery or interventional neuroradiology; 2) Some kind of medication would be used in conjunction with a device outside the brain that allows the medication to become active only in certain targeted areas of the brain; 3) Some sort of nanotechnology with tiny smart robots inside the brain reprogramming circuits. Because the brain is so plastic and easily influenced by the environment, a person will likely need repeated procedures or continuous treatment to prevent the circuitry from reverting to its previous state. And we haven't even talked about prevention, which seems to be Dr. Insel's goal. To do that, everyone would have to get brain-scanned on a regular basis and genotyped.

Certainly, new technologies will come along that I can't even imagine today. However, none of this will be cheap. Even certain cancer drugs today (which aren't that high-tech in the grand scheme of things) can cost hundreds of thousands of dollars per year. So once those super-expensive new brain treatments come out, who will get them? As we've seen with cancer treatment, rich people like Steve Jobs can get genotype-specific treatments and out-of-state liver transplants that ordinary folks cannot afford. Thus, it's hard for me to envision these advances in understanding brain circuitry doing much, if anything, for "public health."

Even trickier are the ethical issues that these new advances would pose for society. If you can correct the circuits causing a person's cognitive dysfunction and hallucinations, then you can certainly damage them as well. Who would we trust with such technology? Pharma? The government? China already locks up dissidents in mental hospitals; imagine if the Chinese authorities could rewire the circuits contributing to a person's desire to protest injustice. And what would happen if we no longer need any human contact, sunshine, exercise, or purpose in life to ward off depression or anxiety? Would we be content to live like the oblivious human batteries in The Matrix?

Before you accuse me of being a nutty conspiratorialist, consider this: If I were to time travel to the 1960's, and I told people that in 50 years time, everyone would have pocket-sized devices that would combine the functionality of TV, radio, telephone, telegraph, camera, newspapers, magazines, books, and myriad other games and diversions; that no one has to remember anything anymore because they can just ask an entity called "Google"; and that people would stare at this device for hours a day, even during social situations like group dinners, I think they would have put me in a psychiatric hospital.

Obviously, not much of what I am saying is new or original. Many science fiction authors have imagined such a dystopia. You can argue that it's the not the NIMH's job to consider all the potential consequences decades or centuries away, and you may be right. But I will say this: The risks of biological psychiatry are great, with uncertain payoffs. Directing those billions of dollars to address issues like transgenerational poverty, child abuse/neglect, interpersonal violence, and the housing of mentally ill in jails and prisons, while boring, will almost certainly reduce the burden of mental illness and help make our society a better place.

A Child Psychiatrist's Thoughts on DSM-5: Autism

This is part 4 of my series on the DSM-5. Previous posts covered general impressions, PTSD, and ADHD.

Quick, according to the DSM-IV section on pervasive developmental disorders (PDDs), what are the differences between autism (offically "autistic disorder"), high-functioning autism, Asperger syndrome, and PDD not otherwise specified (PDD-NOS)? If you can tell me without looking it up that autism requires 6 total symptoms from 3 categories, Asperger syndrome requires 3 symptoms from 2 categories, PDD-NOS requires only 1 symptom, and there's no such thing as "high-functioning autism" in DSM-IV, then you're much more knowledgeable than I am.

Hopefully, it is easy to see why the workgroup tasked with revising the autism diagnosis in DSM-5 tried to simplify this complex chimera into something more comprehensible. Most experts post-DSM-IV have concluded that all of these conditions overlap quite a bit and are best conceptualized as different presentations along a continuum (clinically-speaking, of course; research into etiology is a whole different ball of wax). Hence the term autism spectrum disorder (ASD). Academia has favored using ASD instead of PDD for a while now, and this seems to have filtered into the popular culture over the past decade, as you can see in Google Trends. So what does the DSM-5 change when it comes to the diagnostic criteria for autism?

The 3 categories of autism symptoms in DSM-IV encompass impairments in social interaction, communication, and repetitive or stereotyped patterns of behavior. DSM-5 eliminates the communication category, partly by combining social communication deficits (such as difficulty initiating or sustaining a conversation) with the other social impairments (such as inability to make eye contact or share enjoyment) into one category. Thus, the 2 categories in DSM-5 are "social communication & interaction" and "restricted, repetitive behavior," and impairment in both have to be present to diagnose someone with ASD. The restricted behaviors can now include hypo- or hypersensitivity to sensory stimuli, which is seen in many who are on the spectrum. Language delay, which formerly distinguished autism from Asperger syndrome, is no longer part of the criteria for diagnosing ASD, since that is now felt to mainly reflect differences in IQ.

The impairments can also be "by history," which means that a child who previously had inability to make eye contact but improved after behavioral therapy can still have that count towards the diagnosis. The age criterion has been changed from "onset prior to 3 years" to onset during the "early developmental period." As with many other parts of DSM-5, there is now a dimensional aspect, with 3 different levels of ASD severity based on the extent of impairment in each individual. Also, different specifiers can be added to the diagnosis, e.g. ASD with intellectual disability, or speech delay, or regression in functioning, or specific genetic conditions.

No change is without controversy, and there are some big ones here. Not surprisingly, the elimination of Asperger syndrome as a separate entity sparked an outcry amongst some in the Aspie community. Another controversial aspect is that ASD, unlike other entities such as ADHD, now actually has tighter diagnostic criteria than some of the previous PDDs such as Asperger's and PDD-NOS, resulting in fear that some who already have those labels will lose their diagnosis after the DSM-5 comes out. In this month's Journal of the American Academy of Child and Adolescent Psychiatry, members of the DSM-5 Neurodevelopmental Disorders Workgroup sought to reassure the public (subscription required):

With respect to the PDDs, the DSM-5 has essentially moved from letter grades to a “pass-or-fail” system. Everyone with an existing autistic disorder, Asperger disorder, or PDD-NOS diagnosis (e.g., “A,” “B,” “C”) should simply be reassigned (e.g., “pass”), and not formally rediagnosed unless there is some clinical reason to do so.

It will be interesting to see whether this guidance is followed out in the real world. While the DSM-5 taketh away, it also giveth, in the form of a new category called social communication disorder (SCD). This diagnosis is for someone who has difficulties with "using verbal and nonverbal communication for social purposes" but no restricted, repetitive behaviors. Some of the people who previously would have been diagnosed with PDD-NOS would likely fall under this category. It will also be all too easy to conclude that the DSM-5 is pathologizing social awkwardness and turning it into a disorder, just as many felt that DSM-IV turned shyness into a disorder called social phobia. The truth, unfortunately, will take time to emerge and will likely be complicated, as in the case of shyness vs. social phobia.

For me as a practicing clinician, the new ASD diagnosis is one of the best changes in DSM-5. Soon, I may not even have to reach for a reference book to see if someone meets criteria for an autism spectrum disorder.

NOS Is Dead; Long Live NEC!

In a recent Shrink Rap post on the DSM-5, Dr. Steven Reidbord wrote the following comment:

I don't have much to add regarding DSM 5. I use DSM codes on super-bills I give to patients, so they can receive partial reimbursement by their health plans after paying me directly. Most of the time I use 300.00 (nonspecific anxiety) or 311 (nonspecific depression), and occasionally "parity" codes for major depression etc. I've read all the controversy over the new edition, and it saddens me that our field is so distorted by politics and money. However, I don't see it affecting me much directly.

I have to say that I, too, often use ICD (not DSM) codes 300.00 and 311, which in the DSM-IV are called anxiety disorder not otherwise specified (NOS) and depressive disorder NOS. Working with kids, two other favorites of mine are mood disorder NOS (296.90) and disruptive behavior disorder NOS (312.9). Why such a penchant for such nonspecific diagnoses? Well, for one thing, I believe it truly reflects the patients that I see. I often hear patients or family members talk about "rages" or "anger outbursts" or "mood swings" lasting minutes to hours, none of which are well-captured by a current DSM diagnosis.

I also think that the NOS diagnoses allow clinicians to be humble, by not claiming to know more than we do about the etiology of a patient's condition. Since there are no medications approved to treat NOS diagnoses, to me they feel less "biological." For example, when I say a child has "mood disorder NOS, disruptive behavior disorder NOS, and a parent-child relational problem," I am describing a child that is moody, often has tantrums, and does not get along with his parents. I explicitly say to the parents that I'm not saying there's anything biologically wrong with their child, that these are behavioral problems that can have a multitude of causes, including family dynamics, and that what's going to ultimately make things better is not a pill.

One criticism I've often heard about using a NOS diagnosis is that it is lazy, something done by a clinician who hadn't bothered asking enough questions to reach a firmer conclusion. This is certainly possible. However, in my practice I've generally seen the exact opposite (especially in a Medicaid clinic where I worked): Many patients being diagnosed with schizophrenia or bipolar disorder type 1 or major depressive disorder, when it is clear to me that they never met the criteria for those conditions in the first place. This "mania" for reaching a firm diagnosis, I believe, is largely driven by a need to medicate. If all you have is a hammer, everything looks like a nail.

Thus, I was somewhat peeved to read last year that one of the explicit goals given to the DSM-5 workgroups was:

Eliminate "not otherwise specified" (NOS) diagnoses within categories

The rationale for them wanting to do this is obvious. As blogged about elsewhere, the DSM-5 leadership had hoped to move diagnosis onto a firmer biologically-based footing, and what can be more "fuzzy," biologically-speaking, than diagnoses for which there are only loosely defined criteria? Not surprisingly, the biological psychiatrists had an "epic fail" when it came to biologicalizing DSM-5. Thus, even though DSM-5 has technically eliminated NOS diagnoses, nonspecific conditions will live on in the form of Not Elsewhere Classified (NEC). Here's the difference in their definitions:

NOS: Not Otherwise Specified - This designation is equivalent to the word "unspecified" and indicates that the documentation does not provide enough information to assign a more specific code.

NEC: Not Elsewhere Classified - This designation is used to indicate there is no separate specific code available to represent the condition documented. In this case, the diagnostic statement is specific, but the coding system is not specific enough.

What can I say, except that this actually looks like progress? Clinicians like Dr. Reidbord and myself can not only continue using our fuzzy nonspecific diagnoses, but also instead of having NOS imply that we're lazy clinicians and didn't document enough, we'll be using NEC and implying that it's the coding system (DSM-5) that's inadequate.

A Child Psychiatrist's Thoughts on DSM-5: ADHD

This is part 3 of my series on the DSM-5. Previous posts covered general impressions and PTSD.

If you've been reading the nation's leading mental health blog, you will have been inundated with news and opinion about the rising rates of Attention-Deficit/Hyperactivity Disorder (yes, the hyphen and the slash are both there in the DSM-IV) and abuse of prescription stimulants by college kids. And you may even have come across DSM-5 Taskforce Chair David Kupfer's letter to the editor, in which he defended the DSM-5 by saying "revisions were aimed at helping clinicians more precisely recognize the symptoms of individuals with A.D.H.D. to facilitate the right care for the right person."

Less clear from those articles is what exactly is changing in the DSM-5 when it comes to ADHD, and I hope this post would shed some light on that. But first, some background on the challenges of diagnosing ADHD. Something as broad as an "attention deficit," as dependent on many different parts of the brain working together, and as prone to abuse is inherently going to be a mess when it comes to "accurate" diagnosis. Who can really say at what point "laziness" or "prefers hands-on learning" becomes "ADHD, predominately inattentive?" Thus, misdiagnosis is rampant, and there is a problem of both over- and under-diagnosis of ADHD.

This is nicely illustrated in this study from 2005, which asked parents if their children have been diagnosed with ADHD, and also had the parents complete a standardized questionnaire (the SDQ) about past ADHD symptoms. From the abstract:

Prevalence of clinically significant SDQ ADHD symptoms is 4.19% (males) and 1.77% (females). Male prevalence by race is 3.06% for Hispanics, 4.33% for Whites, and 5.65% for Blacks. Significant differences in prevalence occur across gender (p < .01) and among males across race (p < .01), age (p < .01), and income (p < .02). In the full sample, 6.80% of males and 2.50% of females have a parent-reported lifetime ADHD diagnosis but are negative for SDQ ADHD. Likewise, 1.59% of males and 0.81% of females are positive for SDQ ADHD but negative for parent report of ADHD diagnosis.

Thus, the results support the rough rule of thumb that only about half of kids with ADHD have actually been diagnosed, but about half of those who have the ADHD diagnosis don't really have ADHD. Yes, it's a mess. ADHD is almost certainly over-diagnosed not just among well-off suburban strivers needing "study pills," but also among poor urban youth who may be presenting with behavioral problems under conditions of chronic stress in the family. However, many kids who do have the syndrome are not being diagnosed, for a complex multitude of reasons. Those kids often end up marginalized in school, fall in with the wrong crowd, turn to drugs and alcohol, and have poor outcomes reaching far into adulthood.

The DSM-5 version of ADHD does not change much, but is clearly geared towards decreasing under-diagnosis. The biggest change is that instead of requiring some impairing symptoms before age 7, that age limit is now raised to 12. This is because many children with attention problems, especially if they are intelligent and not especially disruptive in class, can breeze through elementary school without adults noticing that they are not really paying attention. However, once those children reach middle school, they often become overwhelmed by the more challenging material, the demands of going to a different teacher for each subject, and having to keep track of multiple assignments with different due dates.

The 18 diagnostic criteria remain essentially the same. Instead of calling the different forms of ADHD (like combined or predominately inattentive) "subtypes," the term "presentation" is used, since they are not really distinct entities (i.e. most hyperactive children will become less hyperactive over time while continuing to have issues with attention). Also, kids with both autism and ADHD symptoms can now be officially diagnosed with ADHD, since the exclusion for Pervasive Developmental Disorder has been removed. The inattention symptoms have a much needed clarification that they are not due to oppositional behavior or difficulty understanding.

For diagnosis of ADHD in adults, the DSM-5 criteria have been loosened so that patients only need to meet 5 of 9 criteria for inattention, instead of 6 of 9. The manual also provides more examples of symptoms that are relevant to adults.

Ultimately, the question for me is, will the DSM-5 actually solve any problems associated with the ADHD diagnosis in the real world? Sure, it might make the lives of researchers easier since more people would qualify for the full ADHD diagnosis rather than ADHD, NOS. However, I don't think the change in criteria will do anything to improve under-diagnosis, since parents who didn't want to take their hyperactive or inattentive kids to see a doctor before probably still would not do so. Obviously, the DSM-5 won't do anything to stem the tide of over-diagnosis, but I'm also not sure that it'll make the problem any worse. In adults, the problem with diagnosing ADHD is that it is harder to get the third party data like parent or teacher reports that clinicians rely on when making the diagnosis in kids. Anyone can look up the diagnostic criteria and tell their doctor they have those things.

Perhaps it would have helped if the DSM-5 could specify that the symptoms cannot be purely subjective and that objective reports are needed from other sources, but for better or worse, that's not what the book is about. It won't change how I approach those in their late teens or adulthood who come to me saying they have previously undiagnosed ADHD, since I ask those patients to undergo neuropsychological testing so I would have some objective data.

Of course, even with proper diagnosis of ADHD, treatment doesn't necessarily address all the issues or lead to normalized functioning. But that's a topic for another time.