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50 Signs of Mental IllnessA Beautiful MindA Beautiful MindA Bright Red ScreamA Casebook of Ethical Challenges in NeuropsychologyA Corner Of The UniverseA Lethal InheritanceA Mood ApartA Research Agenda for DSM-VA Slant of SunA War of NervesAbnormal Psychology in ContextADD-Friendly Ways to Organize Your LifeAddiction Recovery ToolsAdvance Directives in Mental HealthAggression and Antisocial Behavior in Children and AdolescentsAl-JununAlmost a PsychopathAlterations of ConsciousnessAm I Okay?American ManiaAmerican Psychiatric Publishing Textbook of Neuropsychiatry and Clinical NeurosciencesAn American ObsessionAngelheadAnger, Madness, and the DaimonicAnthology of a Crazy LadyApproaching NeverlandAs Nature Made HimAsylumAttention-Deficit Hyperactivity DisorderAttention-Deficit/Hyperactivity DisorderBeing Mentally Ill: A Sociological Theory Betrayal TraumaBetrayed as BoysBetter Than ProzacBetter Than WellBeyond AppearanceBeyond ReasonBinge No MoreBiological UnhappinessBipolar 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ChildrenEmotions and LifeEmpowering People with Severe Mental IllnessEssential PsychopharmacologyEssentials of Cas AssessmentEssentials of Wais-III AssessmentEthics and Values in PsychotherapyEthics in Mental Health ResearchEthics in Psychiatric ResearchEthics, Culture, and PsychiatryEverything In Its PlaceFamily Experiences With Mental IllnessFatigue as a Window to the BrainFear of IntimacyFinding Iris ChangFinding Meaning in the Experience of DementiaFlorid StatesFolie a DeuxFor the Love of ItForensic Nursing and Multidisciplinary Care of the Mentally Disordered OffenderFountain HouseFrom Madness to Mental HealthFrom Trauma to TransformationGandhi's WayGender and Its Effects on PsychopathologyGender and Mental HealthGenes, Environment, and PsychopathologyGetting Your Life BackGracefully InsaneGrieving Mental IllnessHandbook of AttachmentHandbook of DepressionHandbook of Self and IdentityHealing the SplitHerbs for the MindHidden SelvesHigh RiskHope and DespairHow Clients Make Therapy WorkHow People ChangeHow to Become a SchizophrenicHow We Think About DementiaHughes' Outline of Modern PsychiatryHumanizing MadnessHysterical MenHystoriesI Hate You-Don't Leave MeI Never Promised You a Rose GardenI Thought I Could FlyI'm CrazyImagining RobertImpulse Control DisordersIn Others' EyesIn Two MindsInsanityIntegrated Behavioral Health CareIntegrative MedicineIntegrative Mental Health CareIntuitionJust CheckingKarl JaspersKissing DoorknobsKundalini Yoga Meditation for Complex Psychiatric DisordersLaw and the BrainLaw, Liberty, and PsychiatryLegal and Ethical Aspects of HealthcareLiberatory PsychiatryLife at the BottomLife at the Texas State Lunatic Asylum, 1857-1997Life Is Not a Game of PerfectLithium for MedeaLiving Outside Mental IllnessLiving with AnxietyLiving With SchizophreniaLiving with SchizophreniaLiving Without Depression and Manic DepressionLost in the MirrorLove's ExecutionerLoving Someone With Bipolar DisorderMad in AmericaMad TravelersMad, Bad and 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the SoulOf Two MindsOn Being Normal and Other DisordersOn Our Own, TogetherOn The Stigma Of Mental IllnessOrigins of Human NatureOut of Its MindOut of the ShadowsOvercoming Compulsive HoardingPathologies of BeliefPathways through PainPersonal Recovery and Mental IllnessPersonality Disorder: Temperament or Trauma?Pillar of SaltPoints of ViewPoppy ShakespearePosttraumatic Stress DisorderPsychiatric Cultures ComparedPsychiatric Diagnosis and ClassificationPsychiatric Genetics and GenomicsPsychiatric Illness in WomenPsychiatrists and Traditional HealersPsychiatryPsychiatry and ReligionPsychiatry in SocietyPsychological Dimensions of the SelfPsychology and the MediaPsychopathia SexualisPsychopathologyPsychopathyPsychotic DepressionQuitting the Nairobi TrioRaising a Moody ChildRapid Cognitive TherapyRebuilding Shattered LivesReclaiming Soul in Health CareReclaiming the SoulRecollection, Testimony, and Lying in Early ChildhoodRecovery from SchizophreniaRecovery in Mental IllnessRedressing the 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Pastoral Counseling Treatment PlannerThe PDR Family Guide to Natural Medicines & Healing TherapiesThe Places That Scare YouThe Plural SelfThe Problem of EvilThe Psychology of Religion and CopingThe Quiet RoomThe Real World Guide to Psychotherapy PracticeThe Right to Refuse Mental Health TreatmentThe Rise of Mental Health NursingThe Roots of the Recovery Movement in PsychiatryThe Savage GirlThe Self-Help SourcebookThe Talking CureThe Trick Is to Keep BreathingThe Unwell BrainThe Virtuous PsychiatristThe Way of TransitionThe Wing of MadnessThe Wisdom in FeelingTheoretical Evolutions in Person-Centered/Experiential TherapyTherapy's DelusionsTheraScribe 3.0 for WindowsThis is Madness TooThoughts Without a ThinkerThrough the Looking GlassTo Have Or To Be?Toxic PsychiatryTransforming MadnessTraumaTraumatic PastsTraumatic Relationships and Serious Mental DisordersTreating Affect PhobiaTreating Chronic and Severe Mental DisordersTreating Self-InjuryTreatment and Rehabilitation of Severe Mental IllnessTreatment Plans and Interventions for Depression and Anxiety DisordersTwinsUnderstanding and Treating Violent Psychiatric PatientsUnderstanding Child MolestersUnderstanding DepressionUnderstanding ParanoiaUnderstanding the Stigma of Mental IllnessUnderstanding Treatment Without ConsentUnholy MadnessUnspeakable Truths and Happy EndingsUsers and Abusers of PsychiatryViolence and Mental DisorderVoices of MadnessVoices of RecoveryVulnerability to PsychopathologyWarning: Psychiatry Can Be Hazardous to Your Mental HealthWashing My Life AwayWhen History Is a NightmareWhen Someone You Love Is BipolarWhen the Body SpeaksWhen Walls Become DoorwaysWitchcrazeWomen and Borderline Personality DisorderWomen and Mental IllnessWomen Who Hurt ThemselvesWomen's Mental HealthWrestling with the AngelYou Must Be DreamingYour Drug May Be Your ProblemYour Miracle Brain
Any system that tries to
quantify and qualify the wide, disorderly and vague set of phenomena that make
up the human experience along its continua, is a bugger to teach. When trying
to understand complex equipment, we are all advised, in the words of the sages,
to read the damn manual first. Trouble is, our patients simply refuse to do
this, and so they fail miserably to fit into the neat nosological categories a
committee of people across the seas have created.
However, across the
world, inter-rater reliability is good, when we use the manuals we have created
to pigeonhole human emotional and behavioural aberrations, mainly because we
teach our pupils well.
But still, if Scott Lilienfeld
and others are to be believed, we often create a set of response biases and
availability heuristics that compound the problem, and psychiatry is one of the
few professions where consumers of that service kill their helpers, and
widespread assault is not unheard of.
approaches such as the Rochester model urge us, in
essence, to ask somewhat different questions of the patient. Rather than
trying to ascertain into what neat category, or set of categories a patient’s
presentation fits, a somewhat more humane endeavour might be to attempt to
penetrate the dense phenomenology of the neurobehavioral presentation, and
answer the questions: why this person, why these symptoms, and why now at this
stage of their lives?
Into this arena comes a
rather helpful book, the study guide for the DSM-IV text revision.
Chapters two through
seventeen follow the DSM organisation faithfully, and each chapter begins with
one or two vignettes, a kind of simulator that sets the tone of the chapter,
and these are discussed later. The pupil is thus exposed to the thinking
behind the decision tree-approach of such diagnostic tomes. The ‘core concept’
of the diagnostic grouping is then discussed, with definitions, and overlapping
conditions, which would provide alternatives, are then introduced. The
vagaries of each condition are discussed, and further use of ‘prototypical’
vignettes is the method used to manage the controversies of each diagnosis and
overlapping information which bedevils exclusionary diagnostic attempts. The
step-by-step discussion that follows each is a further tree-climbing, or rather
descending and deconstructive explanation for the diagnosis that is being
illustrated. Over and over again, the common and compounding, confounding
variables are discussed, and finally the precedence of one over the other is
evaluated for each condition. Finally, with a return to the opening vignettes,
the whole process is largely repeated, briefly, with FAQ kind of endings for
each to explain the precedence of this diagnosis, in the face of others.
Of course, in this age
of cyberspace, patients can access most if not all the possible mental illness
definitions, and the drugs prescribed, and one hopes the consumer is becoming
more informed. This may or may not make our job easier, and may of course make
More ominously, drug
companies may begin to target their research, and have already done so, leading
to some weird anomalies.
Why for instance do we
never see drugs emerging that target anxiety, if it exists as a separate entity
from depression? Why are the antidepressants so good at treating anxiety, but
why do some of them increase the sense of arousal or dysphoria in the first few
days? Most of us believe we know the answers, but that is so often
Most students will
struggle with the DSM, and most of mine joke that they went into psychiatry
because it was the best way to forget general medicine and medical practice!
categorisation of human experience being what it is, this book answers many of
these questions in a novel way. The use of the invariant headings for each
chapter, picked out in bold, lull the student into a rocking and cradling along
the lines of each category, and thus set up a preservative framework for each
contact with the patient, creating a clinical mindset, which, although hardly
creative, cuts out the middleman, the golem of psychiatry, namely the gut feel,
the hara gai, the availability heuristic, or confirmatory bias.
This is indeed where
such manuals, or rather guides to manuals, are so vital. We do after all
recognise what we know, and see only what we look for so often. How do we
reliably go after the answers to why this person, why these symptoms, why now?
Not all psychosis is schizophrenia, it is after all a rare 1% illness, but
psychosis is not, coming as it does from all sorts of heteromodal cortex
dysfunction. On page 168 for instance, there is a discussion of a psychotic
presentation. The sudden onset of the symptoms AND his elevated blood pressure
indicate for the author an immediate caveat that there may be an organic
basis for his presentation. We do not abandon medicine when such formulations
are made. For many of us this seems just simple normal practice, and yet many
of my students simply forget to do the medical workup and certainly often
forget to make the attribution necessary.
Worse, without such
workbooks, and a plodding approach to nitpicky diagnosis, fundamental
attribution errors abound. We do not see bad brain, we see bad person. Each behavior
has a homeostatic purpose after all, but we often see, lets say, the experience
of thirst as being separate to the search for something to drink, but of
course, they are one and the same thing.
I was told the other day
by a consultant that my patient’s problems were behavioural and psychological,
nothing to do with his brain. I responded that if such problems had nothing to
do with the brain, then we should all become proctologists, since that is where
the consultant’s opinion was coming from, which explains my behaviour of late,
which is seeking new employment: but I do mean this. We have to embark on a
systematic approach to teaching dangerously linear tomes such as the DSM by
seriously enforcing the non-linear medical model, and such workbooks train such
thinking as well as it can be done.
The chapter on the most
vexing of diagnoses, the personality disorders, is the most fun obviously, but
lacks much of what one would hope to see in this biological age. However it
also stresses, without saying, a conservative approach to labelling patients as
sad, bad or mad. This temperate tone dominates much of the book, and is the
sign of a wise writer, who tries to teach with a balance, and mostly succeeds.
There is nothing to
replace this book that I have seen, and Fauman has spent a long, long time on
it, and this shows. I cannot see how any programme that teaches the DSM can
function without it, and every student of psychology and psychiatry has to buy
this one, and work through it day by day, group by group.
Not only students. If
Scott is to be believed, and I have no reason to doubt him, we all need to do
this once a year, and get CME credits for it. We simply hear what we want to
hear, and the validity of our expert pronouncements is tainted.
One of my colleagues
recently was asked to confirm the detention, under the mental health acts, of
an elderly patient, on the basis of schizophrenia. She had decompensated after
being told that she had to have a cataract operation. By the time he saw her,
she had become scared that her eyes would be cut up, and now she was being
poisoned (depot typical). Her concrete and overwhelmed brain was now being
insulted and she was to be locked up as insane. He found her simply
overwhelmed, and would not detain her or confirm the diagnosis, to the horror
of his colleagues.
I worked though her case
as this book suggests, and the book agrees with my colleague, this is not
schizophrenia. Why have his detractors, all eminent, not read a handbook
It's always going to be
news to us all, and deconstructs. As Laing said, if you don’t know you don’t
know, then you think you do know. On the other hand, if you don’t know that
you do know, than you may think you don’t.
It’s a nice, easy to use
book, and required reading for neophyte and lofty proctologist, all.
Otherwise, to paraphrase Othmer, Othmer and Othmer in their family
collaboration in the last Psychiatric Clinics of North America edition of 1999,
we will be diagnosing fat ankle syndrome for a long time to come, and
forgetting our medicine, and our brain.
© 2003 Roy Sugarman
Roy Sugarman, PhD, is post of
Clinical Director of the Clinical Therapies Programme in Liverpool (Sydney) and
Clinical Associate Professor at the University of New South