Interdisciplinary Review of General, Forensic, Prison and Military Psychiatry and Psychology and the related subjects of Behavior and Law with the occasional notes and comments by Michael Novakhov, M.D. (Mike Nova).
Friday, August 10, 2012
The Limitations of Our Diagnostic Classification: Beyond DSM’s Checklists - By Melvin Gray, MD |July 27, 2012 - PT
The Limitations of Our Diagnostic Classification: Beyond DSM’s Checklists
By Melvin Gray, MD |July 27, 2012
Dr Gray is a practicing psychiatrist and Professor Emeritus from Midwestern University (formerly the Chicago College of Osteopathic Medicine). He is the author of the textbook Neuroses: A Comprehensive and Critical View.
It is imperative for a psychiatric classification system to integrate theories of matter, consciousness, emotion, personality, social interaction, and behavior into as much of a unified system of diagnosis as possible. For a diagnostic classification system to be meaningful, it should include at least the following components: physiological expression of the central and autonomic nervous systems, cognitive appraisal (evaluation), subjective experience, and behavioral activities.
Current psychiatric classification, for the most part, excludes the emotional dimension, yet emotions are innately stored as neural programs within the brain. They are expressed in universally and socially understood ways and have common qualities that help determine the adaptiveness or non-adaptiveness of a particular action, in a particular situation. Emotions affect the whole person from the level of the neuron to a worldview. They can even be considered as an altered or special state of consciousness. Emotions can often exist independent of other states but usually interact and influence coexisting states or processes, either in consciousness or non-consciousness.
If this is so, then no behavioral, perceptual, cognitive, or neuronal condition can be absolutely free of emotion—and therein lies the problem of current psychiatric diagnosis and treatment. Since our current system is mainly empirically based and materialistic, it reflects only a partial and perhaps naive understanding of the human person. Knowledge gained from other sources, such as intuition, creativity, spirituality, and subtleties of feeling and emotion, may be lost in this type of approach. The loss of these qualities of mind has led to an undesirable alienation of psychiatry from a humanistic approach to treating the mentally ill.
A case presentation may help our understanding:
Mary is a slim, 32-year-old woman who speaks rapidly, gets upset easily, and is inclined to cry at the least provocation. In her work for an automobile agency, she expresses doubt about her secretarial capabilities. During the past 4 months, she and her boyfriend, Paul, began what was her first sexual relationship. Recently, they talked about “love,” and this made Mary realize that Paul is not her ideal partner. Questions about their compatibility began to crop up in her mind: he is not handsome enough, they lack common interests, their cultural and educational backgrounds are different, he could be more considerate of her, etc. After thinking over these concerns for about a week, Mary decided to terminate the relationship, even though she “liked” Paul.
After the breakup, Mary was sad, but within several weeks she began feeling better, even though she was not dating. Her daily life became one of going to work, returning home, and remaining alone. After another month of this routine, she developed a reluctance to leave her high-rise apartment for any reason other than shopping and work. One day while entering the elevator, Mary became extremely anxious. She described how her heart pounded and her chest tightened, as sweat rolled down her back and she became dizzy. Before the elevator reached the street level, her tension became so great that she impulsively exited the building. Once outside, she slowly calmed down and eventually returned to a normal state. This sequence of events occurred repeatedly, ultimately resulting in Mary’s inability to go to work, and even a reluctance to leave her apartment.
The symptoms I have described were indications for pharmacological and psychotherapeutic intervention. At the patient’s request, I submitted statements to the insurance company, listing the dates, costs, and time spent for each treatment, as well as the appropriate diagnostic and procedural codes. (Was this an infringement on my patient’s privacy?) Problems with the insurance payment began immediately. First, with respect to the prescription, the insurer wanted justification for use of a brand-name drug. Why didn’t I prescribe a generic instead? Then my billing statement was rejected: they initially wanted my Social Security number, but that was not good enough. After much arguing, this “provider” was required to submit his PIN number and medical license number. When all was said and done, it took over 6 months before payment was received.
Corporate medicine, lawyers, the pharmaceutical industry, and insurance companies are using psychiatry as a tool. They use the current diagnostic system to encourage and enhance the use of medicines by psychiatrists. Lawyers and patients can also use the diagnostic system in the pursuit of lawsuits. Moreover, the current diagnostic system does not consider the specific individuality of patients and deters creative thinking. What the Academy of Psychiatry created, the government and the industrial complex have used for their own advantage—at the expense of psychiatrists and their patients.
Mary’s case illustrates the minimum components necessary for a “comprehensive diagnosis.” Beginning with a stressful situation that upset her equilibrium, Mary appraised the circumstances with Paul, both positively and negatively, and made a decision that led to their breakup. She later developed an irrational fear that resulted in stimulation of her autonomic and voluntary nervous systems. This, in turn, motivated an impulsive action to escape from what she interpreted as a dangerous situation.
But does this “rational explanation” really explain Mary’s behavior—or is there something more? In his 1934 poem The Rock, T. S. Eliot suggests an answer, in the very questions he raises: Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?
Logical and scientific explanations of causation are limited and open to falsification; there is something to be known beyond what science or deductive logic can offer us. We need psychiatrists who are experts in dealing with the human condition; who understand the depth of human feelings; and who share the joys, agonies, and distresses of their patients. We do not need psychiatrists who fit people into categories and slots and treat them as if they are robots, according to the dictates of a recipe book called The Diagnostic and Statistical Manual.
Suggested Readings • Chalmers D. Facing up to the problem of consciousness. J Consciousness Stud. 1995;2(3):200-219. • Damasi A. A Feeling of What Happens: Body and Emotion in the Making of Consciousness. New York: Harcourt Brace; 1999. • Dennett DC. Sweet Dreams: Philosophical Obstacles to a Science of Consciousness. Cambridge, MA: MIT Press; 2006. • Dunbar F. Emotion and Bodily Changes. 4th ed. New York: Columbia University Press; 1954. • Eliot TS. Preface. In: Thoughts for Meditation: A Way to Recover From Within. London: Faber and Faber; 1951:12. • McDermott JJ, ed. Introduction and Preface. In: The Writings of William James: A Comprehensive Edition. Chicago: University of Chicago Press; 1977:9-134.