DSM Diary: Part 3
For a change, I decided to spend the morning at a research session unrelated to DSM5.
And I am amply rewarded, reminded that research and debate on classification systems is among the least interesting and clinically meaningful areas of research.William Bunney is preoccupied with techniques to relieve depression within 24 hours rather than 4-6 weeks, and reviewed such low-tech interventions as sleep deprivation (and a theory that it changes gene expression in clock genes that control circadian rhythm), deep brain stimulation (not for first-time callers to the mental health system!) and ketamine intravenous infusions. All of these techniques produce reliable and reproducible improvements in 24 hours, but the challenge is to keep someone well.
A presentation on tic disorders in children covered the evolution from psychoanalysis through antipsychotic drugs to the latest in behaviour therapy (habit reversal therapy), with the head of child psychiatry at Weill Cornell arguing that drugs are rarely needed now. It’s good to see child psychiatry moving beyond its late arrival to medications toward other evidence-based interventions. Similarly, a leader in obsessive compulsive disorder showed persuasive evidence that exposure and response prevention is likely the best approach to obsessive compulsive disorder, either alone or as an adjunct to antidepressants, and in her latest study antipsychotic drugs as an adjunct were no better than placebo and far worse than exposure and response prevention. The room never filled for this very rich and clinically relevant symposium.
I took my usual front-row seat early for a session I was sure would be packed to the gills: perspectives on good psychiatric management in the treatment of borderline personality disorder.
Presenters included my friend and CAMH colleague Shelley McMain who has done one of the major research clinical trials of dialectical behaviour therapy versus good psychiatric management in borderline personality disorder, along with Paul Links, a former Toronto colleague who is now Chair of Psychiatry at the University of Western Ontario. They were joined by John Gunderson of Harvard and the woman who runs Gunderson House, the extraordinarily expensive, 60-day inpatient unit at McLean Hospital. Surprisingly, the crowd was sparse – despite most attendees being clinicians.
Shelley presented the results of her major trial comparing dialectical behaviour therapy and good psychiatric management (GPM) in a randomized design. The bottom line at the end of treatment and two years later was no difference between the two.
John Gunderson went on to characterize GPM – or, as I described it in a question afterward, being a “generic psychiatric mensch”. It is now packaged as a specific form of treatment, complete with manuals, workshops, etc. It appears to be little beyond being a good psychiatrist. And, when I asked, they had not evaluated the GPM model for any condition other than borderline personality disorder.
For my final APA encounter, I attended a session on psychiatrists who write for the public, since this is something I do from time to time. About 100 people showed up.
It was chaired by Richard Friedman, who has written for the New York Times regularly over the last 10 years. Lloyd Sederer spoke next. He is now the mental health editor of the Huffington Post. Norman Rosenthal, a prolific author, followed him.
Sally Satel was the final speaker. She is the author of Drug Treatment: The Case for Coercion, PC MD (how political correctness is corrupting medicine) as well as the forthcoming Brainwashed: The Seductive Appeal of Mindless Neuroscience. She speaks skeptically of “neuro-entrepreneurs”, who promote things like neuromarketing. She wrote her new book with some trepidation because she respects the vast majority of neuroscientists.
Ten years ago, she was the subject of a protest at the APA in San Francisco, describing her as a “right wing fanatic” because of her PC, MD book in which she critiqued the psychiatric survivor movement. The American Enterprise Institute gives her the freedom to write what she wants, especially in the policy realm. She acknowledges it as a right of centre place but describes herself as a centrist.
Her book One Nation Under Therapy is a challenge to the assumption of vulnerability in the wake of trauma. In her style of challenging assumptions, she finds thinking about addiction as a chronic and relapsing brain disease neither clinically helpful nor satisfying. She has also critiqued disability payments for veterans with PTSD who haven’t been through any treatment at all. She gave a marvelous analogy to giving people full disability for a motor vehicle accident before they have had any surgery and rehabilitation. Diagnosis is not the same as prognosis. Despite all this, she doesn’t embrace the title “right wing psychiatrist”.
She spent the first five years of her academic career in substance abuse at Yale testing out new drugs for addiction. She was turned off by the “entitlement culture” at the VA where she worked and saw it as a barrier to rehabilitation.
People seemingly upset with her talk – the most engaging and provocative talk of the symposium – kept walking out as she spoke. It was an amazing display of intolerance.
I didn’t learn anything special from this symposium, although it was interesting to see these very public voices in psychiatry in person. But it was an appropriate finale to the conference for me, after sitting for six hours per day over the last four days in windowless aircraft hangars.
The conference and the trip are over for me; I’ve discarded my admission badge and packed up my bag. I’m eager to be home. My suitcase is now weighted down with DSM5 publications – along with the sense that the new classification system is neither a major advance nor a major difference to the practice of my profession. It won’t make previously well people ill or previously ill people well. It’s a tool which, like all tools in medicine, requires clinical judgment in its use and respect for the larger individual, family and social context in which its many described symptoms reside.