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Monday 2 September 2013

The Crack-Up Book - Courtesy of the Huffington Post website



The Crack-Up Book
Posted: 06/26/2013 

"In a real dark night of the soul, it is always three o'clock in the morning, day after day."
That is how F. Scott Fitzgerald described his mental state in a series of essays called
The Crack-Up, published in 1936, a few years before he died. The Crack-Up was Fitzgerald's description of his own experience with depression and alcoholism, and obliquely, his wife Zelda's bipolar disorder.
Yet nowhere in the essays are such psychiatric terms used. Instead, Fitzgerald uses metaphor and poetry. He writes that he "cracked like an old plate," and lived in a state of emotional bankruptcy in a world of "dangerous mist" and "villainous feeling." He sums up the last, lost decade of his life: there had been "too much anger and too many tears."
Thankfully Fitzgerald was writing before the publication of the American Psychiatric Association's diagnostic manuals, the fifth edition of which, the DSM-5, was recently published. Had the DSMs existed, even a writer of Fitzgerald's stature would have been tempted to draw from symptom lists to describe his inner torment in The Crack-Up.
The DSMs have become victims of their own success. To be sure, the DSM-3, published in 1980, was a necessary step forward for the psychiatric world. Earlier manuals were steeped in unclear Freudianisms with little consistency in the language of even basic psychiatric diagnoses. Doctors, and perhaps more importantly, insurance companies, had no way to talk to one another. DSM-3 became quite unexpectedly a runaway success, a best seller. (The last version made $100 million for the APA.) But each successive edition seems to have gone haywire, adding over time, hundreds of new diagnoses. Which in turn has led to mass over-diagnosing and over-medicating.
A central problem is that the DSM's diagnoses are categorical, rather than dimensional. That is, to qualify for one of the 400 or so diagnoses in today's manual, one has to meet sharply drawn criteria. The DSMs have set up diagnosis as a light switch that is either on or off. But psychiatric conditions are not absolute and differ wildly in intensity from person to person. A dimensional perspective -- like that of a dimmer switch, as psychologist Simone Hoermann has put it -- more accurately reflects the realities of psychiatric suffering.
The result is a mass confusion between severe and persistent mental illness -- the truly mentally ill -- and the worried well. Millions of Americans are mistakenly walking around thinking they have a mental illness. One in ten of us in on antidepressants. Since the mass impact of the DSMs, psychiatry has been all off or on (mainly on), with no dimmers.
There are two ways out of this mess. The first is to ignore the DSM-5 entirely and wait until biological psychiatry can be used as a basis for a truly scientific diagnostic system. Thomas Insel, director of the National Institute of Mental Health, did as much recently when he said that NIMH would no longer use the DSM to guide research, favoring instead new categories based on neural circuits and cognitive functioning.
The second approach is to actually listen to patients as they tell their stories and describe what they are feeling. As William Osler, Canadian physician and a pioneer of modern medicine, said a century ago, "Listen to your patient. He is telling you the diagnosis." Besides, listening is good treatment. Research shows unequivocally that the more patients feel understood, the better their satisfaction with treatment. The better their satisfaction with care, the better their compliance and clinical outcomes.
I tell my students, if you want to learn about depression, don't read the DSM. Read The Crack-Up. If you want to understand grief, read Joan Didion's The Year of Magical Thinking. If you want to know about Post-Traumatic Stress Disorder, read Wilfred Owen's poetry about World War I. This is how Owen described shell-shocked soldiers (he was one himself) in "Mental Cases":
These are men whose minds the Dead have ravished
... their eyeballs shrink tormented
Back into their brains, because on their sense
Sunlight becomes a bloodsmear; night becomes blood-black ...
Until the biology catches up, we would do well to heed the lessons of the literary and, yes, psychiatric experts -- Fitzgerald and Owen: no categories, all dimension.
My 12 Best Tips on Psychiatric Diagnosis
Posted: 06/17/2013 10:38 am

We already had a crisis in psychiatric diagnosis before DSM-5. It is a sure sign of excess that 25 percent of us qualify for a mental disorder and that 20 percent are on psychiatric medication. Unless checked, DSM-5 will open the floodgates and may turn current diagnostic inflation into future hyperinflation.
Below are my 12 best tips on how best to ensure accurate and safe diagnosis.
  1. The less severe the presentation, the more difficult it is to diagnose. There is no bright line demarcating the very heavily populated boundary between mental disorder and normality. Milder problems often resolve spontaneously with time and without need for diagnosis or treatment.
  2. When in doubt, it is safer and more accurate to under-diagnose. It's easier to step up to a more severe diagnosis than to step down from it.
  3. Children and teenagers are especially hard to diagnose. They have a short track record, varying rates of maturation, may be using drugs, and are reactive to family and environmental stresses. The initial diagnosis is likely to be unstable and inappropriate.
  4. The elderly are also hard to diagnose. Their psychiatric symptoms may be caused by medical and neurological illness and they are prone to drug side effects, interactions, and overdose.
  5. Take the time and make the effort. It takes time to make the right diagnosis -- adequate time for each interview and often multiple interviews over time to see how things are evolving. Except for classic presentations. quick diagnosis is usually wrong diagnosis.
  6. Get all the information you can. No one source is ever complete. Triangulation of data from multiple information sources leads to a more reliable diagnosis.
  7. Consider previous diagnoses -- but don't blindly believe them. Based on their tenure, incorrect diagnoses tend to have a long half-life and unfortunate staying power. Always do your own careful evaluation of the person's entire longitudinal course.
  8. Constantly revisit the diagnosis. This is especially true when someone is not benefiting from a treatment that is based on it. Clinicians can get tunnel vision once they've fixed on a diagnosis, become too married to it, and are blinded to contradictory data.
  9. Hippocrates said that knowing the patient is just as important as knowing the disease. Don't get so caught-up in the details of the symptoms that you miss the context in which they occur.
  10. If you hear hoof-beats on Broadway, think horses, not zebras! When in doubt, go with the odds. Exotic diagnoses may be fun to think about -- but you almost never see them. Stick with the bread and butter.
  11. Accurate diagnosis can bring great benefits; inaccurate diagnosis can bring disaster.
  12. Remember the other enduring dictum from Hippocrates: First, Do No Harm.

(Excerpted from the introduction to my book, 'The Essentials of Psychiatric Diagnosis' by permission of Guilford Press).
This is a summary of my best advice on how to do an accurate diagnosis.

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