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Hear no evil, see no evil

Some of the members of the psychiatric establishment who have been assigned to articulate de new diagnostic classification of mental illnesses which will be known as the DSM-V, seems to be isolated in the pinnacle of the Olympus.
In November of 2008 I wrote to one of these scientists and, as of May of 2009, I have not received a response to my certified letter.  Since I don't expect any significant change in the absurd misconception of the methods use to make pediatric psychiatric diagnoses, I am publishing this letter to win the right to say, ten years down the road, I TOLD YOU SO:
 

Dear Dr. Chatoor:
This note intends to beg your intervention to prevent what could be a catastrophe for many of the children we treat. I am referring to the development of the DSM-V and the implications that it could have on the lives of millions of individuals around the world.
Similar to what it is happening now with our economic crisis (the decisions taking place in D.C. are going to have a significant impact that will be felt far beyond our frontiers), the final product that will be called DSM-V could be either a blessing or a curse for psychiatric patients.
During the past eight years I have published several articles and Letter to the Editor questioning the validity of Conduct Disorder (CD) and Oppositional-Defiant Disorder (ODD) as legitimate diagnoses in an attempt to support the standpoint on this matter of well-known psychiatrists such as Hagop Akiskal, Andres Pumariega, Ronald Pies, Charles Huffine and others.  I have gathered data (of a respectable size) to support this perception that I am willing to share it with you, should you be interested in reviewing it.
In the meantime, please, allow me to enumerate a few ideas in support of my view regarding CD and ODD:  

They are symptoms of mood, anxiety or psychotic disorders, not independent medical syndromes.

• In the "Pro & Con" exchange (Journal of Bipolar Disorders, Review & Commentaries) I stated that categorizing ODD as   diagnosis is equivalent to consider a sore throat an illness instead of a symptom.

• In a paper published by Dr. Magda Campbell in the Journal of the AACAP (34(4):445-453, April 1995) she reported that  lithium was effective in the treatment of CD.  Subsequently, other researchers have reported that risperidone improved  symptoms of ODD and CD. I believe that these improvements are linked to the well-documented effectiveness of lithium  and second generation anti-psychotics as mood stabilizers.

• Non-physicians professionals (school counselors, teachers, social workers) DIAGNOSE (?) children and send them to a pediatrician to get a Rx for the most powerful medications, amphetamines.  Please, consider that these individuals are well-intentioned but not qualified to make a differential Dx.  How could they know that a child does not have Absence Seizures, PTSD (flashbacks can make a child look inattentive) OCD (repetitive thoughts, rituals, rigid rules) and the most important of all, genetic endowment.  On a daily basis I conduct Second Opinions on children who have been removed from the care of their parents who, in many cases, have mental illness.  In some instances the teacher or S/W was not even aware that "Johnny" was not a biological son.  http://www.psychiatrictimes.com/adhd/article/10168/53786

• Violent behavior and defiance are not features of ADHD.  More important, rage episodes should not be "treated" with amphetamines because we know as a fact that this type of drugs can induce violence, paranoia, hallucinations, etc.  Dr. Nora Volkow has published PET imaging showing that cocaine and methylphenidate generate similar pictures when given to volunteer subjects.  As you can imagine, nobody would consider given cocaine to a violent person.

• The existence of ODD as a Dx gives health insurance companies' reviewers an excuse to deny a needed hospitalization.  They allege that ODD does not require inpatient treatment and force psychiatrists to send home a violent child or adolescent.  Frequently a youth ends up in a correctional facility on charges of aggravated assault (or worse) because of the mental health system's failure to help him or her when aggression and defiance were the symptoms of a serious mental illness.

• In the current DSM-IV ADHD is classified in the same category as "Disruptive Disorders" which would make sense except for the fact that Bipolar Disorder is not in this group. You probably would agree with me that a manic person can be disruptive not only to those around him or her but his or her behavior disrupts most aspects of regular-life functioning.  

• DSM-IV emphasizes the importance of age limits and developmental age (instead o chronological age). Still we see children with Mental Retardation or Autism Dx with "comorbid" ADHD in clear disregard of the exclusion criteria:
The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Unfortunately, many prominent psychiatrists, such as John Walkup, M.D. would vehemently  defend a position that clearly departs from DSM-IV's guidelines, i.e., they  claim that Autism and ADHD can coexist in the one person.  
And the list could go on but I don't want to overwhelm you and I rather wait until I hear from you if you are able to help or if introducing changes in the ODD/CD field is beyond your possibilities. In the meantime, please, allow me to wish you a very happy Thanksgiving Day.
Sincerely,
Manuel Mota-Castillo, M.D.
Lake Mary, FL  
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This letter was followed by another one sent to the Editor of the journal Psychiatric News:

Dear Editor:
I would like to address some of the issues included in a report on the DSM-V development, so nicely written by Joan Arehart-Treichel.  By reading it I realized the APA is facing the most important crossroad of its history but, at the same time, the sad possibility of missing the opportunity to bring drastic changes to the way we diagnose mental illnesses.
I dread the perpetuation of several fallacies that are ruining thousands of lives hurt by wrong diagnoses and treatments.  For example, most experts believe that ADHD can have many comorbidities and one of them is quoted in Ms. Arehart-Treichel's chronicle as saying that irritability could be a sign of depression. Assertions like this one go undisputed even though experts also concur that ADHD does not have a mood component.

By the same token, prominent professors ignore DSM-IV-TR's guidelines and teach that ADHD can co-occur with Autism. Ironically, my office's receptionist knows that autistic children do not pay attention to people and their failure to look at the teacher does not make them ADHD.  What she does not know is what I see:  rituals, obsessions and aggressive behaviors gone out of control when these children are given psychostimulants.
Finally I take issue with the phrase "similarities of symptoms" because it is a misperception of what should be called "overlapping of symptoms." Case in point, impaired attention could be the manifestation of manic racing thoughts, nervous agitation of social anxiety, thought blocking of active psychosis, intrusive thoughts of OCD, flashbacks of PTSD, "brief disconnections" of Absence Seizures and, by exclusion, ADHD.  
This is the real problem. Clinicians have subverted DSM's guidelines and give ADHD the benefit of diagnosis of first choice, instead of been "what it is left after all possible causes of inattention have been ruled out."

I hope DSM-V will bring solutions instead of more confusion because we already have the experience of DSM-III, which created the Oppositional-Defiant diagnosis to appease the psychoanalytic establishment.  We should remember that 40 years ago children "could not have depression or bipolar disorder" and we would not think of OCD or social anxiety in the pediatric population.  Consequently, children with manic defiance or fear of going to school, to mention just two situations, were called oppositional-defiant, without a search for etiology, as we do in any other medical specialty.
Manuel Mota-Castillo, M.D.
Assistant Professor of Psychiatry
St. Matthews Medical School.    

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In June of 2009 I put together a few lines and sent it to the American Psychiatric Association's journal. The idea was to warn to the psychiatic community of the serious consequences that keeping the ODD diagnosis in DSM-V will bring to youths of most countries:

 
I want to address the commentary by Drs. Regier, Narrow, Kuhl and Kupfer,
"The Conceptual Development of DSM-V." 1 15 years ago Dr. Nancy C. Andreasen, as this journal's editor, wrote an editorial commemorative of "100 years of Schizophrenia" which included this reflection:
“The Ahistorical Fallacy rests on three faulty assumptions.  The first assumption is that ‘proposition X’ must be true because it is what the ‘experts’ are teaching.  The second assumption is that ‘proposition X’ must be true because it is the most recent one to be put forth. The third assumption, which buttresses the first two, is that ‘if information increases, knowledge increases as well.”
 
A few years later, I posted a "distress call" titled "APA: We have a problem." Professor Rodrigo Muñoz, then APA's President, had the courtesy of answering my concerns about the diagnostic confusions in pediatric psychiatry. He stated that DSM-IV provided exclusionary criteria to avoid unjustified "comorbidities."
I share my apprehension again because the possible elimination of diagnoses that several authors2,3 consider unnecessary or dangerous, is not part of the DSM-V agenda.  I praise the above-mentioned commentary because it touches areas that nobody dared to question before. For example, the authors say "The focus of the study group on spectrum disorders included assessment of the spectra of mental disorder syndromes that cross existing diagnostic boundaries…"
Unfortunately, other journals 4 published papers that reflect the trend of analyzing statistical data in disregard of the genetic endowment of the sample been studied. These works are impeccable in many ways, except for one:  There is no mention of the genes passed on from the abusive and/or mentally parent to the child.
This issue is relevant to the development of DSM-V because diagnoses like Oppositional-Defiant Disorder (ODD), Conduct Disorder, Intermittent Explosive Disorder and Disruptive Behavior Disorder NOS are just lists of behaviors already included in well-defined psychiatric illnesses.
Besides the negative consequences of avoiding the real disease, a practical issue hurts thousands of children across the country: HMOs reviewers use ODD to refuse needed hospitalizations to patients with treatable illnesses.
Equally negative is diagnosing a manic, anxious or psychotic child as "comorbid" ADHD and ODD6 and prescribing medications that worsen the symptoms. Additionally, the child's self-esteem is injured because he or she feels impotent when blamed by a behavior beyond their control.

 
References:
  1. Regier, D., et al., The Conceptual Development of DSM-V, AJP, 166:6, June 2009.
  2. Huffine, C. (2000) Should the Conduct Disorder diagnosis be struck from the DSM-V?” Clinical Psychiatric News, Volume 28, No.4.
  3. Mota-Castillo, M., Is It Really ODD?, Psychiatric Times, Feb. 2004.
  4. Sourander, A., et al., Childhood Predictors of Completed and Severe Suicide Attempts; Archives of General Psychiatry; Vol. 66, No. 4, April 2009.
  5. Roth, T., Lasting Epigenetic Influence of Early-Life Adversity on the BDNF Gene; Biological Psychiatry, Vol. 65, No. 9, May 2009.
  6. Mota-Castillo, M., The Journey out of Madness, Psychiatry Times, June 2009.

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Finally, here is one evidence that the fight against the fallacy of Conduct Disorder as a real diagnosis has been going on for years:  

Vol. 3, No. 8 / August 2004
Is Conduct Disorder Real?

I am rebutting “How to reduce aggression in patients with conduct disorder” (Current Psychiatry, April 2004).

A 15-year-old ended his first two visits with me under police custody and was committed to a psychiatric hospital both times. After the first commitment, his grandmother filed a petition alleging unruly/delinquent behavior, and a judge ordered the boy to take his prescribed mood stabilizers. That was necessary because the hospital psychiatrist had determined that the boy was not mentally ill and that his grandmother needed parenting classes.
The youth’s original diagnosis—conduct disorder and oppositional-defiant disorder (ODD)—contradicted my diagnosis: bipolar disorder, mixed.   During the second hospitalization, a psychiatrist diagnosed the youth as having attentiondeficit/hyperactivity disorder (ADHD). The doctor prescribed methylphenidate and oxcarbazepine, but the patient’s guardian did not consent to the medications.

Facing a sentence at the county juvenile detention center, the youth started taking olanzapine, 10 mg at bedtime, and lamotrigine, 25 mg bid titrated to 50 mg bid, as I had prescribed. His grandmother says that he no longer exhibits defiant behavior. At his third visit, he shook my hand and said: “Thank you for finding the right medications for me.”
I have seen hundreds of similar cases over 10 years. To paraphrase a colleague, diagnosing somebody with conduct disorder or ODD is like diagnosing a patient with a runny nose after a thorough emergency room examination.

I applaud the American Association of Community Psychiatry’s efforts to urge the American Psychiatric Association (APA) to abolish the conduct disorder diagnosis. I also support the many researchers who are requesting elimination of conduct disorder and ODD. These are not real and specific diagnoses but are alleged syndromes that express several conditions.

Manuel Mota-Castillo, M.D.
Florida

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