Monthly Archives: November 2013

The Mental Health Divide, Part II

continued from October 24, 2013)

More about the five axes of the DSM-IV-TR:

• Axis I relates to Clinical Disorders, which include all forms of depression (severity and recurrence), anxiety and mood disorders, PTSD, schizophrenia and psychoses. Think of these as disorders that are acute or chronic, biologic or reactive, but generally responsive to psychotherapy alone or in combination with medication. • Axis II reflects Personality Disorders, or features and traits that are lifelong characteristics that often interfere with daily functioning, relationships, and adaptability. Depending upon the patient’s insight and motivation, these traits are addressed via a range of psychotherapeutic approaches, either alone or in combination. Examples include Dependent, Avoidant, Obsessive-Compulsive and Narcissistic Personality Disorders. The most commonly used diagnosis is 301.9 – Personality Disorder NOS with (fill in the blank) Features when more than one trait is problematic. An IQ that falls below a certain threshold is also listed under Axis II. • Axis III lists the physical conditions present in the individual, and these are particularly pertinent to patients with chronic pain, injury or serious illness. • Axis IV outlines the psychosocial factors such as family dynamics, housing, occupation and finance that are affecting, or affected by, the individual. • Axis V measures the Global Assessment of Functioning (GAF), a numerical scale that assesses an individual’s ability to function in all areas of life, based upon the combination of Axes I-IV.

The DSM-IV-TR vs the DSM-V

Since its inception in 1952 and throughout its revisions, the accuracy and validity of the Diagnostic Statistical Manual (DSM) for classification of psychological symptoms has been challenged. Dr. Allen J. Frances, Professor Emeritus at Duke University, chaired the DSM-IV-TR task force (year 2000 Text Revision) and publicly objects to the impending release of the DSM-V.

An active blogger for the Huffington Post, he urges clinicians to ignore it’s changes altogether, asserting that the new version is vaguer than ever and will lead to labeling healthy individuals with its lowered threshold for criteria. In one of his blogs he states that the DSM-V is “offering its untested new diagnoses that will mislabel millions of the worried well as mentally ill”.  Parents of autistic children have the opposite concern, that their child will no longer fit in that diagnostic category and be denied access to medication and therapy.

Frances states that the DSM-V offers no leeway in differentiating, for instance, alcohol addiction vs dependence vs social use. The manual’s authors counter that early recognition will result in early intervention, but many practicing clinicians fear that the endpoint will be over-diagnosis that misidentifies normal variations in behavior.

The National Institute of Mental Health (NIMH)

On July 3, 1946, President Harry Truman signed the National Mental Health Act, which called for the establishment of a National Institute of Mental Health (NIMH). The process of diagnosing without etiology is the fundamental distinction between the DSM’s function and the conceptual model now proposed by the National Institute of Mental Health.

NIMH rejects all DSM versions and is devoting its considerable financial and scientific resources to the premise that all psychological conditions are biologic or chemical in nature, originating in specific regions of the brain, and thus amenable to medical intervention.  The stakes are significant – for insurance reimbursement, financial grants for research, pharmaceutical financing, and one hopes, the well-being of patients. Citing the difficulty in properly diagnosing mental health disorders when forced to choose an ICD code, in 2008 NIMH implemented its Strategic Plan, a diagnostic process using Research Domain Criteria (RDoc).

This plan utilizes a matrix of Constructs (rows) that are grouped into five Domains of Functioning, and seven classes of Variables (columns) with an eighth column for paradigms. The goal is to classify mental disorders along a continuum of biologic and genetic markers, neurological circuitry and specific regions of the brain. The attempt is not to diagnose a mental disorder by looking at the overall patient presentation, but to find one symptom that is present across a variety of disorders, eventually pinpointing the physical location of the symptom. This intersection would identify the origins of disease, and science (psychopharmacology) would intervene to avert mental disorder. This theory ignores the empirical research on the greater efficacy of “talking therapies” either alone or in combination with psychopharmacology, and even NIMH agrees that this lengthy research offers no immediate relief to patients.

Opponents to RDoc fear that severe illness (schizophrenia, bipolar disorder) may go untreated if the affected individual does not express a specific gene. They question the validity of research that is conducted solely in laboratories and does not involve practitioners in the field. NIMH counters that RDoc is an open document for which they have sought input from the medical community.

The term “Ivory Tower” designates an environment or atmosphere where intellectuals engage in pursuits that are disconnected from the practical concerns of everyday life” . The last sentence in the first paragraph of Draft 3.1: June, 2011 states that one of RDoc’s goals is “…to facilitate commentary from scientists and other interested stakeholders…” Should there be concern that patients and practicing clinicians are not mentioned in this sentence?