jazz and conversation, from the foot of Mt Belzoni (ikkyu2) wrote,
jazz and conversation, from the foot of Mt Belzoni

DSM-V's a-comin' out, doo dah, doo dah

The anti-psychiatry movement is out in full force lately, due to the imminent release of DSM-V. Here's a Slate article reviewing a book that hops on this trend; I have read 5 or so similar articles on the topic in the past week.

A lot of folks are hopping on this bandwagon: the idea that psychiatry diagnoses are subjective. One contrast that is frequently made is to an infectious disease diagnosis. For example, this author points out "With scarlet fever, you can trace the symptoms to the presence of strepococcus bacteria in the body."

True, as far as it goes. (No one mentions the Koch postulates, which are of course the strong form of the ability to assert causation in infectious disease.) But here is something not addressed by the author or the Koch postulates: Many people have streptococcus bacteria in the body. Not all of them will develop clinical infections; not all of those who do will develop scarlet fever. Even those affected with a Group A strep infection sometimes don't develop scarlet fever. Is this of any interest to those making this analogy? It should be, because it demonstrates the limits of knowledge about illness and in particular the definitions of illness that we use. (Antibiotics are often given to asymptomatic Group A strep carriers, particularly mothers and those who have frequent contacts with the infirm; and such people, who would otherwise meet the definition of robust good health, have died of anaphylactic reactions to those antibiotics. Now are you interested in the definition of disease that we use? You should be.)

Criticizing working docs on the grounds of science is a dicey affair and every article I have read thus far is doing it wrong. Why do docs do anything? Because a patient shows up somewhere - the hospital, the clinic - a marked place where a patient-doctor encounter can occur. Most of these patients are in need of help; the vast majority are seeking help, a few have been brought for help without consent or against their will by paramedics, police, or the court system.

A patient seeking help, I find, is usually not interested in science; and when he or she is, the interest is almost always misplaced and governed by anxiety. A patient in need of help is in need of help. Help is what doctors give and diagnosis is part of the process that is used to determine what help is appropriate.

Trouble is, as we have expanded to the information society people have opened the doctor's toolkit, peeked in, and begun complaining about how it is used. No one complains about which snake a plumber uses to clear out your stopped up toilet; if the toilet flows, the plumber's methods are best left to his own sewage-reeking management, and we hope he drives away pretty soon. The doctor's process used to be similarly obscure, cloaked in medical Latin, and no one gave a damn. Nowadays everyone gives a damn; HIPPA, the supposed privacy act, in fact ensures that government and insurance have access to all rendered diagnoses, and CMS, the US de facto regulator of healthcare, won't even permit a doc to receive pay for work where the diagnosis isn't encoded by picking it from a list. Patients are encouraged to know their diagnosis and Google it, and anyone who has ever attended a cocktail party where people 40+ are present understand that the right to medical privacy is routinely waived - people prefer that EVERYONE know the sordid details of their diagnoses and treatments.

Nowhere is this more apparent than behavioral medicine, which is also called psychiatry. And we see that there is a lot of public discourse lately, about psychiatric diagnoses and how they are constructed.

For instance, much is made of the fact that in 1977 (The web seems to have gotten the idea that it was 1973) the APA repudiated their prior diagnosis of homosexuality as a behavioral disease.

You know what's been nearly eradicated since the 1970s? The parade of men through docs' clinics, saying "Doc, I can't stop having sexual thoughts about sex with other men. What's wrong with me?" Nowadays, most of those men know what the issue is, and most of them come to understand there's nothing wrong with them. Boy howdy, was that ever not the case in, say, 1972. You think those men didn't have a problem? You think it was OK, back then, for a guy to be gay and not know it and think it was an illness to be cured? Did that guy really truly not have any problem at all?

In fact, those men, men who think about sex with other men and hate themselves for it, they are still around, though there may be fewer of them. Nowadays they are looked at, not as medically ill, but, at least on the Web in articles written by wise pundits, as objects of popular pity and scorn. That's good, presumably - an improvement based on the fruits of our newly gained wisdom - because it is much better to be pitied and scorned than to try to get help from a doctor. Those guys commit suicide at an alarmingly high rate - but who cares? They were pitiful creatures to begin with. And, they've been spared the indignity of diagnosis, and that is a much higher good! We know that now!

Quibbling about disease definitions is all very high and learned, and the brilliant, masterful pundits who analyze these details for Web publication are no doubt the world's most erudite and incisive minds. I for one am grateful to receive the benefits of their staggeringly vast wisdom.

Yet, when I am confronted with the reality of a patient, complaining of symptoms, in my examination room, I am sorry to report - I weep to report - that that wisdom is not available to me, at least not in a form that I can use. Practical, specific courses of action in such a case - patients complaining of crippling anxiety preventing them from doing activities of daily life - or so depressed that they lose the ability to read and write - those practical, specific, courses of action are surprisingly absent from the clever critiques I have been reading - articles that, from their breezy tone, seem to have been dashed off in an afternoon (but which of course doubtless were inspired by decades of daily reflection upon, and study of, the topics under discussion.)

More fool I, the hapless physcian, then, when confronted with a patient who has these problems. I must endure the foul reek of their odor, because their mental health problem has interfered with their ability to clean their body. I must endure physical assault, because their mental health problem has interfered with their ability to make good decisions. I must endure the critique of their loved ones because those have read articles on the Internet pointing out that the process I am trying to go through - the healing process - is less than perfectly scientifically rigorous.

In fact, what a schmuck I am! How much better to be a Web pundit - someone who KNOWS what is right and wrong in all of these situations, and who can essay their insight briefly and then never actually worry about what to do in the situations I find myself in daily as a working physician! That guy is smart! I must, by contrast, be an idiot.

Here is something, however, that I can do that a web pundit cannot: as a working physician with the modern practical tools of psychiatry at my disposal: I can help those people who come to me for help.
Tags: health, healthcare
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