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LETTERS TO A YOUNG PSYCHIATRIST

By Seyyed Nassir Ghaemi, MD, MPH
11 de abril de 2013


Comments on the Psychiatry Times Web as a respond to the article...

Professor Ghaemi touches an issue that has been one my concerns for many years going back to when I was in training and noticed how some of my fellow Residents were more concerned with following the "recipe" than to take a close look at the person in front of them. I have to concede that because of my previous experience in journalism I was already skilled in the art of listening with an open mind, without pre-conceived ideas.

This is so much a priority to me that just yesterday I was consulting a respected friend, Professor Dr. Ronald Pies, about the possibility of writing a commentary on what I perceived as a misguided scientific methodology when it comes to making diagnoses in children and adolescents. For example, many doctors apply the ADHD label to patients that already have a diagnosis that explains their lack of attention, impulsivity and restlessness, i.e., Autism, Social Anxiety or Bipolar Disorder. Something similar is happening when the "oppositional-defiant" (ODD) label is giving to a child that refuses to follow directions and is disrespectful to authority figures as part of the clinical picture that results from a grandiose, elevated mood.

I can also corroborate Dr. Ghaemi's assertion of the impact DSM has in the whole world because I am a participant of the Red of Hispanic Psychiatrist (hosted by Dr. José Angel Saviñón) which include psychiatrists from dozens of Spanish-speaking country currently practicing in many areas of the planet. The sense that I get from discussions and posting I read in that venue is that DSM is "the law of the land." Furthermore, American journals publish academic papers from psychiatrist in a multitude of countries and they also reflex DMS guidelines.

The DSM was a blessing a first because it brought a common language to researchers beyond the frontiers but, in my view, it has become a burden that disseminates a rigidity of thinking and tunnel vision-like approach that interferes with the unbiased and open-minded look that we should take when evaluating every patient. Besides, its inexplicable disregard for the importance of the genetic influence is, again from my perspective, equivalent to a wrongdoing. If you think than I am exaggerating, think of a patient I evaluated in 2003: Born in a State psychiatric hospital where the parents managed to avoid the security that kept male and female apart and had an intimate encounter that resulted in pregnancy. Six years later, a psychiatrist at a teaching hospital determined that patient's aggressive and unruly behavior was due to ADHD and ODD even though it was documented in the initial evaluation that both parents have schizophrenia. In that case and several others that are very similar the psychotic symptoms were very resistant to treatment because, I suspect, the prolonged exposure to amphetamines worsened their real illness.

I understand that everybody is entitled to an opinion but I also believe that "At least, do not harm" still remains the guiding principle in this profession.
Manuel Mota-Castillo, M.D. | April 28, 2013
Lake Mary, Fl
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by Nassir Ghaemi | May 02, 2013 8:29 PM EDT
I'd like to thank those who've commented. I agree with Manuel that DSM had benefits in 1980s which we've long outlived; now its failures are not recognized sufficiently be the profession. I agree with Dr Nair that the British tradition described is an important resource that we have lost; if only we could return to reading those excellent old texts, instead of memorizing DSM criteria.

I am intrigued by Dr Snyderman's comment. I dont know that I am an apostate, or if I am one, I'm not certain that I'm newly an apostate. I will say this: I have changed my views on a number of matters in psychiatry in the past decade or so; and I hope to keep changing my views in future decades. Some of my changed views have to do with new knowledge: I simply didnt know that DSM-IV was "pragmatically" made-up to suit the wishes of its leaders, until its leader explicitly admitted this fact in the last few years in the context of the DSM-5 debates. I have become less trusting of drugs than I was a decade or two ago, earlier in my career, as I've seen from the inside, as a researcher, the paucity of the research evidence for so many common practices. I've been rethinking the nature of how we treat patients, and how we diagnose, consistently for the past two decades, in deeper study of psychiatric thinkers, like Jaspers and others, and I've been learning more from important personal mentors over time, like A. Koukopoulos and others. So I suppose as my knowledge and thoughts have evolved, I've changed my views on some of these matters. This may be apostasy, I suppose, but perhaps not since I don't think we should ever be fully committed to any views that we won't change with new knowledge.
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