Happy Holidays!  It has been awhile since I have published a newsletter.  I wanted to, but during the past several months I have not had enough free time to rub two rocks together and something had to give. 

This issue, however, should get me out of hot water with those of you who said, "Where's my newsletter"?  I will include up-to-date research on health care issues, as well as  a paper I had written regarding shortcomings of the DSM-IV diagnostic coding.  If you don't know what DSM-IV is, don't feel alone.  Most don't!  DSM-IV criteria does, however effect us both directly and indirectly.  It even effects our children.  Take a look, it is fairly interesting, if not somewhat disturbing.  

I wanted to include some of my own research, but until publication requirements are met I will have to wait.  I may be able to share this information in January or February.

I will, of course, be including one of Eileen's favorite Christmas recipes and even one of my own!

Finally, I would like to wish you all a very Merry and Safe Holiday Season!  Christmas seems to become more commercial each year, but as we get older, we realize that that is not what it is really about! 

Enjoy the time with your family and friends, but do take a little time to reflect on yourself as well.  If you are not where you want to be in your life, there is no better time to make positive changes.  Renewing yourself is also what Christmas is about!

Enjoy this issue and I will see you again in 2004! 

(p.s. In early 2004, I will be doing some work at the Attorney General's office as well as practicing full time.  This, hopefully, will not delay future issues of my E-news, but I promise the end result will be worth any inconvenience.

Take Care

Dr. Frisch

Are Your Ears Ringing?

Those of you who have suffered with ringing in your ears know what a bother it can be.  You may not have realized, however, that there can be many reasons for your ears to ring.  Aging, trauma, disease, medication and even pressure changes can make your ears ring.  Before we start to decide WHY your ears may be ringing, let's first explore HOW your ears ring.

The ears have nerves to them.  All signals, both good and bad, are due to nerve transmission.  The primary nerves innervating the ear are the vestibulo-cochlear nerve (cranial nerve 8 / acoustic nerve) with some crossover of the vagal nerve (c.n. 10) and trigeminal nerve (c.n. 5).  The small circular 'mess' in the lower right-hand corner of this picture is the hearing complex .  When the sound strikes your eardrum, this is the pathway it takes to your brain.  There pathway of hearing is easily interrupted.  Arthritic changes of the circular canals, trauma or drugs can alter how and what type of signals get to your brain.  An altered pathway can lead to regular or constant 'ringing or buzzing' sensations.  Anyone who has been diagnosed with Meniere's disease understands what this is like. 

The type of ringing in the ears I described above is a problem directly related to the ear itself.  There can be ringing or buzzing in the ears, however, without actual ear damage.  This is most commonly related to the 5th cranial nerve ( trigeminal nerve).  One of the more common reasons for the trigeminal nerve to induce a ringing or buzzing in the ears is due to a jaw (TMJ) problem.  If the jaw is not dropping properly on opening, it will deviate to one side or the other.  If this happens each time you open your mouth, you have TMJ!  It may not be symptomatic yet, but the process is there.  Some people develop TMJ after an accident, but others develop the condition independent of any reported trauma.  

One of the easiest ways to tell if you have an improper opening is to have someone watch you open your mouth.  they will see the deviation.  You can watch yourself open your mouth in a mirror, but it is harder to evaluate because you want to cheat!

TMJ is correctable!  You need to ACTIVELY retrain the opening mechanism.  It won't correct itself.  Mouth guards and bite plates will only provide temporary relief of pain.  They will not correct the physical imbalance because a passive treatment rarely fixes an active problem.  Structural adjusting with the Activator instrument and home exercises are still the best way to stabilize the condition until something better comes along!  The relief noticed is often immediate and long lasting.

If you have ringing in the ears you  need to be evaluated.  Your chiropractor can easily determine any imbalance and make the needed corrections.  If you are unresponsive to conservative care, added testing may be warranted.  You should first rule out 'structure and function' imbalance prior to seeking drugs or surgery because neither are very effective at relieving a TMJ disorder and the ear ringing/buzzing often remains. 

If you or a family member suffers with ringing in the ears please call this office to set up a consult. If you are too far away to come here we can find someone in your county or state who can perform the proper testing for you.

So That's How They Do It !

This is an actual paper I presented regarding limitations of the DSM-IV diagnostic criteria that the psychology profession uses to diagnose us and our children.  This paper was not not meant to discredit the profession, but rather, point out some very obvious flaws that do need correction.  The format transferred fairly well to FrontPage for the web, but there were some crossover problems that I apologize for.  Enjoy the reading! 

Is the DSM-IV an Accurate Analysis of Mental Health?

Glenn Frisch

Augsburg College

Is the DSM-IV an Accurate Analysis of Mental Health?

DSM is a classification of mental health conditions.  It stands for the Diagnostic and Statistical Manual of Mental Disorders.  There have been several revisions of this statistical guide with the latest version being termed DSM-IV TR.  This analysis paper will review past and current criteria for establishing diagnosis sets.  The historical establishment of the DSM criteria will be investigated, as will the rational behind childhood, adolescent, and adult diagnosis of mental health conditions.  Published research involving the use of DSM-IV will be included.  Clinical and research data coupled with opinions regarding shortcomings of the DSM-IV classifications will also be presented.  I will conclude this topic paper with recommendations regarding the use of DSM-IV that I feel might be of benefit to individuals and society.

The original intent of classifying mental disorders was to garner statistical data.  This data collection of psychological maladies in the United States began as far back as 1840.  The census at that time included the terms “idiocy/insanity”.  This early collection process was crude, but effective in its solitary goal.  With time, it was recognized that patients in a psychiatric hospital needed a more complete diagnosis than just “insane”.  By 1880 there were 7 categories of mental impairment established (DSM-IV-TR, 2000).  The categories included mania, monomania, paresis, melancholia, dementia, dipsomania and epilepsy.  We now know that epilepsy is classified as a physical disorder, unless discussing co-joining factors that result directly from suffering with epilepsy (depression, alienation, etc.).  An accurate diagnosis associated with a mental condition was difficult to obtain within the criteria established.  This allowed for less than stellar diagnostic patterns that had no cohesiveness and were deemed secretive, if not totally strange by the general public.

The DSM-I was originally created in the 1952 as a guide or directive for treating patients in the area of mental health.  Up until that time, much of the structure of care and ultimate treatment outcomes was directly dependant on the doctor’s, individual analysis and recommendations.  The DSM-I and its successor DSM-II had drawbacks, however, as the guidelines were restrictive.  The DSM-I had only 3 categories (psychological, social, and biological) and attempted to establish clinical diagnoses and care within those parameters.  The DSM-I guide first introduced the term reaction when describing psychological processes and impairments.  The DSM II was nearly identical to the DSM-I with the exception of the removal of the term reaction.  This early change showed the continual evolution to which psychological terminology and criteria are subjected.

The DSM guides have typically been aligned as closely as possible with the International Classification of Diseases (ICD).  This international classification allows for coding of disorders, but does not give criteria for establishing a diagnosis or care directives.  This has placed the American Psychological Association (APA) and the World Health Organization (WHO) at odds with each other over the years.  With the establishment of the DSM-III in 1980 the division between ICD and DSM grew even larger.  The DSM-III included 16 categories of mental disorders as recommended by Washington University investigators.  The psychosis category of the DSM-II was divided into psychotic disorders and affective disorders.  The category of neurosis was also divided into 4 separate categories (anxiety, somatoform, dissociative and affective), which would impart a more accurate diagnosis to the patient.  The DSM-III was designed for clinical effectiveness and the ICD-9 coding had to be modified according to the American standards.  The DSM-III stimulated research as a result of the distinct disorder categorization and the collection of data within those categories.  The increase in research reinforced credibility of the psychology profession.  Another positive affect of the DSM-III classifications was that it established the psychological field as a scientifically based form of health care.  Conditions could be documented, tracked and even predicted due to prior data collections within specific categories.  Gone were the days of the generic diagnosis that seemed to be cloaked in secrecy.  With the DSM-III came a clinical definition of disorders, criteria required to fit the disorders, and care recommendations based on statistical data as well as the empirically acquired data.  The categories of the DSM-III were:

1.    Disorders usually first diagnosed in infancy,  

     childhood or adolescence

2.    Delirium, dementia and amnestic and other

     cognitive disorders

3.    Mental disorders due to a general medical 

     condition

4.    Substance-related disorders

5.    Schizophrenia and other psychotic disorders

6.    Mood disorders

7.    Anxiety disorders

8.    Somatoform disorders

9.    Factitious disorders

10.       Dissociative disorders

11.       Sexual and gender identity disorders

12.       Eating disorders

13.       Sleep disorders

14.       Impulse-control disorders not elsewhere  

     classified

15.       Adjustment disorders

16.       Personality disorders

The implementation of the DSM-IV (1994) and the DSM-IV-TR (2000) allowed for expansion of the criteria set forth in the DSM-III.  Most notable was the use of simplified sets of criteria used to make a diagnosis, a historical use of empirical data and a reliance on existing research.  These three categories give the DSM-IV greater flexibility in making a clinical diagnosis (Hamstra, 1994).  But, it is this flexibility of the criteria that also allows for discrepancies and false positives/negatives when determining an appropriate diagnosis.  There is a frequent overlapping of conditional criteria and this may result in an inaccurate or inappropriate diagnosis being administered. 

A diagnosis is a categorization of a set of symptoms or findings.  There are problems that can arise when a definition (diagnosis) of a set of symptoms is implemented.  This can include labeling of the patient according to a diagnostic title given by a therapist.  Patients who are given a ‘title’ of a diagnosis may begin to hold that diagnosis responsible for their actions and behavior, while neglecting their own personal responsibility in resolving the condition.  Diagnosis classifications can and often do coincide with societal fads, but fads evolve.  Diagnoses attributed to ‘toxic shock syndrome’ and ‘silicon breast implantation’ of the 1970’s have been largely unsupported with time.

What may not evolve with time are cultural variations of expectations, interpretations and cultural acceptances in a society.  What may be perfectly normal behavior in one culture may seem bizarre or even immoral in another.  A condition of hyperactivity in an American culture may be perfectly normal in an African culture.  Diagnostic criteria must be malleable enough to incorporate personal and social variations to insure accuracy.  A more in depth look at inconsistencies of the DSM-IV and DSM-IV-TR will be discussed later in this paper.

Diagnostic Criteria are necessary to first, establish that something is wrong and second, to categorize the symptoms or objective findings into a classification that can be used for remission of the condition.  But, at what age are diagnostic criteria relevant?  At what age is it appropriate to begin determinations of function versus dysfunction according to social norms?  There is quite an extensive body of work addressing childhood mental conditions.  This includes, but is not limited to ADD, ADHD, and conduct disorders.  The literature tells us that children have disorders that require attention and stabilization, but is the analysis correct and are the criteria sets accurate? 

The DSM-IV-TR states that the diagnosis of Attention- Deficit/Hyperactivity Disorder may be used when certain criteria are met.  The criteria are as follows:

Symptoms of hyperactivity-impulsivity persisting for at least six months to a degree that is maladaptive and inconsistent with developmental level.  Six or more must apply.

1.  often fidgets with hands or feet or squirms in seat

2.  often leaves seat in classroom or in other situations in which remaining seated is expected

3.  often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

4.  often has difficulty playing or engaging in leisure activities quietly

5.  is often “on the go” or often acts as if “driven by a motor”

6.  often talks excessively

7.  often blurts out answers before questions have been completed

8.  often has difficulty awaiting a turn

9.  often interrupts or intrudes on others (e.g., butts into conversations or games)

     There is also a section of 9 statements regarding inattention to co-join the hyperactivity-impulsivity category.  Those statements are similar subjective classifications as the hyperactivity-impulsivity category so I will not list each separately.  The diagnosis of Attention-Deficit/Hyperactivity Disorder is classified into three categories:

·        314.01 Attention-Deficit/Hyperactivity Disorder, Combined type.

·        314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type.

·        314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type.

·        Adolescents not meeting full criteria may be classified as “In Partial Remission”

My first comment after reading these definitions of ADHD is “Define often”.  These classifications are too subjective to be considered objectively scientific.  What child sits quietly, doesn’t talk excessively, plays quietly or isn’t “on the go”?  These statements practically describe a normal child.  I am sure that there are instances of unruly, destructive or abusive children, but nowhere does the DSM-IV-TR state that “the child is rude”, “the child is verbally abusive during play” or “the child intentionally runs in front of cars during play”.  These are conditions that would raise concern to me, not if the child talks out of turn. 

It would appear that most of the classifications listed could be improved or corrected through guidance, discipline and adult examples of proper behavior.  I do not feel that the classifications of ADHD are concretely indicative of a disorder.  There is too much room for error in diagnostic criteria when diagnosing ADHD.  I am not sure if the criteria are actually objectively diagnostic at all.  There is therapist bias; parent demands that something be done and school/teacher influence that may all drive a diagnosis that is improper.  The answer to this problem seems to be medication with Ritalin and behavioral counseling.  But, is this the best treatment?  I have my doubts.  The criteria appear to be grossly inadequate for a definitive, objective diagnosis that a condition exists at all.  If these classifications of mental disorders are so important to our defenseless young, why are we being so inept in determining if a condition exists at all?

This lack of a ‘gold standard’ in diagnosing ADHD was discussed in a recent study of DSM-IV reliability between researchers and ‘real world’ clinicians (Lewczyk, 2003).  It was reported that researchers had a higher inter-examiner reliability (46.7%) than did clinicians (23.3%) in diagnosing ADHD.  The discrepancies between the two groups were attributed to methods of interviewing and a general lack of understanding of how treating clinicians make diagnostic decisions.  It was implied that if the clinicians would follow research interview guidelines they might achieve similar results.  They did not discuss the possibility that the ‘real world’ clinicians were actually interacting with the subjects, had a closer interaction with patients concerns, and were able to evaluate the patient more accurately without crossover diagnoses that would give false positive findings.  I am curious as to whether the clinicians were expected to ignore clinically objective data and follow predetermined guidelines?  With the subjectivity found in the DSM-IV diagnostic criteria it would seem to me that any degree of true clinical objectivity would be of benefit to the patient.  An item of concern in this study was that the research group agreed on a diagnosis of ADHD less than 50% of the time. 

ADHD does appear across cultures as well, but only when the same research based interview and diagnostic criteria are used.  Latin American children appear to be more active and talk more when distressed than do American children (Rohde, 2002).  This cross-cultural difference shows that there may be no ‘gold standard’ available to truly diagnose ADHD within and between groups of children.  If this is the case, the criteria need to be modified to acknowledge these differences.  ADHD is a widely given diagnosis that, at least in the United States , seems to be a babysitting tool for educators and parents alike.  If the diagnostic criteria are not objective enough to solidify a dysfunctional disorder on a consistent basis then we may be looking at a diagnostic trend, rather than a pathological entity. 

Additional classifications of childhood mental conditions showed disagreements in reliability as well.  A review of the literature for childhood anxiety disorders revealed discrepancies of validity criteria.  A study of Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions (Silverman, 2001) involved testing 62 children (7-16 years) and their parents to evaluate the reliability between groups for generalized anxiety disorder as well as other mental conditions.  The reliability between parent and child for generalized anxiety disorder was determined to be excellent.  The DSM-IV criteria were used and the same researcher performed both the test and the retest.  It was implied that the structure of the interview process was key to the favorable statistical outcome.

The diagnosis of childhood anxiety, however, suffers from the same subjective limitations as ADHD.  The simple variance of adding an additional researcher for the second test (Muniya, 2003) appears to confound the results of the Silverman study.  When different interviewers administered the child and parent testing to 45 children and their parents the reliability between the groups was poor.  Their explanation for the results included the possibility that a sole researcher, over time, may be better able to determine a relationship between symptoms and a diagnostic disorder.  This would seem to add credence to the insight of the clinician in forming a workable diagnosis, rather than operating within criteria sets that may be weak or possibly invalid. 

It would appear that there are acknowledged limitations to the ability of the DSM-IV to accurately diagnosis a mental disorder in children.  I feel that the DSM-IV may be a necessary evolutionary step in the diagnosis of childhood mental disorders, but that the criteria for impairment allow for large inaccuracies.  This would apply directly to the popular diagnoses of childhood ADHD and general anxiety disorders.  The qualifying criteria statements may be manipulated for convenience or monetary gain by the therapist.  The DSM-IV also contains a new ‘safety net’ in administering a diagnosis that should be of concern to doctors, therapists and patients.  It reads: The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.  Including this sentence is like throwing a blanket around a weak or vague set of symptoms to give them credibility and validity under any category.  The doctor or therapist should be keenly aware that giving a diagnosis based on weak criteria in childhood might have repercussions for that child during adolescence and beyond.

Adolescent children are at a developmental stage in their lives both physically and emotionally.  This stage of rapid physical growth and mental development is due, at least in part, to the increase in hormone levels in the body.  These hormones stimulate physical growth, influence emotions of irritability and anger, mood swings, periods of confusion about ‘who they are’, and sexual reproductive urges.  The adolescent individual is no longer a child.  Too many physical changes and mental gains have occurred to classify the teen as a child.  They are on their way to becoming a mature adult, but the transition is difficult.  I am somewhat concerned that a diagnosis given in childhood may be inappropriately applied to a teenager. A teenager is a completely different individual than the child who was given the original diagnosis.  The psychology field does not seem to favor the idea that a diagnosis may completely resolve.  In the DSM-IV-TR, there is a footnote, which states that an adolescent may be given a diagnosis of In Partial Remission. This diagnosis may be applied even if the child does not present with the same criteria for which the original diagnosis was given.  It seems that once a child is given a diagnosis it may be considered a permanent tag.  It seems fairly obvious that an improper diagnosis may easily follow a child into adolescence and beyond.  This is not fair to the child or teenager.  At what point is a diagnosis considered resolved?

It has been proposed that ADHD may actually be a learning disorder (Boschert, 2001).  The crossover (overlap) of diagnosis criteria may have allowed ADHD to take center stage at the expense of a more accurate or insightful diagnosis of a learning disorder.  Boschert sites the growing evidence that ADHD results from a failure to inhibit or delay behavioral responses.  Rather than suffering with a pathological entity, teenagers with a diagnosis of ADHD appear to be more impaired in processing speed and color naming than other teenagers.  This would imply that a learning process has been improperly established or interrupted.  Steps should be taken to begin evaluating at what stages of processing this occurs.  If ADHD is truly a learning disorder, rather than a medical entity, medication will not correct the problem.  It may actually contribute to a worsening of the condition by interrupting normal neurotransmitter transmission.

Up to two thirds of children and adolescents given a diagnosis of ADHD will carry that diagnosis into adulthood (Leuzzi & Spandorfer, 2000).  The new DSM-IV criteria insure this possibility by new language in the text.  An adult diagnosis of ADHD must include a history of ADHD as a child or teen.  The new language allows for a regressive diagnosis of adult ADHD because they may not have known they were suffering with the disorder.  This language is awkward and allows the doctor or therapist to give a post-dated diagnosis because of a set of current symptoms.  This seems wrong.  The risk is too high for fraudulent diagnoses for the sole purpose of financial gain from a third party payor (insurance company).  It may also give improper validation for a lifetime of error or intentional wrongdoing.  How many convicted criminals would endorse the opportunity to say that the reason they committed a lifetime of crimes was due to an undiagnosed disorder called ADHD?  The legal profession has probably already attempted this defense.  I don’t feel that we should encourage that validation without stronger objective data.

One of the more interesting studies regarding the progression of ADHD from childhood to adulthood was a 14-year longitudinal Dutch study (Hofstra, 2002).  In 1983, parent- ratings were gathered for 1578 children and adolescents ranging in age from 4-16.  The subjects were garnered from the general Dutch population and were determined to have behavioral and/or emotional problems at that time.  The children were not allowed to give self-ratings.  The 14-year follow-up of these children and teenagers determined that children who suffered from parent-reported behavioral and emotional problems were more likely to suffer from similar or related problems in adulthood.  This included depression, adult ADHD as well as other behavioral problems and psychopathology. 

I feel that this study has some problems associated with its structure and analysis.  First, the original data was collected from parents and did not have child or adolescent interviews.  Secondly, the data was subjected to criteria available in 1983 and not current day criteria.  I feel that the follow-up collection of data in 1997 was confounded in its collection process.  The parents were not interviewed.  Instead, the former children and teenagers performed the rating scale.  This seems very subjective in its relevance.  By not allowing the children to be interviewed in the first study, but relying on their reporting in the second study would seem to be comparing apples and oranges.  The data is different.  Additionally, the new data obtained was subjected to the DSM-IV criteria and compared to the 1983 data as though they were equal in balance and strength of content.  This comparison may not seem to carry too much weight in itself until that comparative data is allowed to make a prediction.  That is precisely what happened in this study. 

As a result of the parent-reported problems in 1983 and the 14-year follow-up of child and adolescent reports, predictions for adult behavior were made.  The Dutch researchers concluded that according to the DSM-IV criteria, their ‘prospective examination’ revealed that high levels of childhood behavioral problems (primarily rule breaking) were directly related to adult disruptive disorders.   The DSM-IV would appear to have met the needs for continued care for mental and behavioral disorders, even when the subject pools were different for data collection.  The topic of labeling as a child being somewhat responsible for adult self-reporting of problems was not discussed.  I feel that this study was negligent in its data collection methods and the subject pool used.  The flexibility of the DSM-IV discussed earlier in this paper appears to allow for this type of data collection to appear to be relevant, when in fact it should be scrutinized very closely.  There may actually be some relevant data in this longitudinal study, but I feel that they reached too far with their claims.

With the data presented, it would be fairly easy to understand how adult diagnoses of mental conditions ‘rollover’ from childhood or adolescence.  The DSM-IV has given the mental health field a liberal wand with which to establish expansive, ongoing diagnoses and treatment parameters for nearly everyone who seeks help or guidance from a counselor, therapist or psychologist/psychiatrist.  This establishes and encourages ongoing, lifetime care and the dependency it may create.

Diagnosing adult conditions like ADHD is different than that of children and adolescents.  Diagnosing adult ADHD can be difficult because there are rarely distinct characteristics available to fit the criteria required for a diagnosis (MacReady, 2003).  Because of this, empirical data is often called upon to aid in part of the decision-making process.  MacReady states that up to forty percent of adults develop ADHD later than childhood, even though the DSM-IV states that a childhood diagnosis of ADHD was needed for the adult diagnosis (unless the new criterion are used).  She says that it is more appropriate to look at an individual’s past for possible indicators, but take that knowledge “with a grain of salt”. 

MacReady’s opinions on adult ADHD were refreshing in that she stressed that a clinician or researcher should rely more on the data at hand, incorporated with continued observation and discussion to implement a proper diagnosis.  I believe she understands the shortcomings of the DSM-IV criteria and the inaccuracies that may occur when trying to establish a diagnosis.  MacReady is not alone in her critique of the limitations of the current fourth edition of the DSM.  Researchers and clinicians alike are becoming more vocal in their assessment of limitations regarding the DSM-IV criteria.

A significant, new variation in the DSM-IV criteria is that nearly fifty percent of all diagnoses include a new ‘clinical criterion’.  This new criteria was introduced with the intent of making the clinician’s job of diagnosis easier and more accurate than before.  The problem with the new criterion language is that is so vague and expansive that nearly every symptom could qualify for a diagnosis even if it is merely a ‘normal’, but stressful period in one’s life that will pass (Spitzer, 1999).  The language states that nearly fifty percent of all symptoms qualify for a diagnosis on Axis III if the symptomatology causes “clinically significant distress or impairment in social, occupational, or other important areas of functioning”.  The language is too vague and expansive.  If a person is temporarily depressed because of the death of someone close they could qualify for a diagnosis of a mental disorder, rather than acknowledging that it is simply a period of bereavement.  We are supposed to be sad at times like that.  You likely have a problem if you are not unhappy when someone near you dies. 

Spitzer notes further that the clinical significance criterion was not based on research, clinical data or empirical evidence.  The language was established on ‘conceptual grounds’.  The task force who assembled the DSM-IV text felt that it might help eliminate some of the false positive diagnoses.  A false positive is when a condition is diagnosed, but does not actually exist based on criteria.  The new language actually insures that nearly all diagnoses can be supported.  This might not be legal fraud, but I question if it qualifies as moral fraud on behalf of every patient given a psychiatric diagnosis.

A study evaluating the differences between clinical and research practices in establishing borderline personality disorders (Zimmerman, 1999) concluded that clinicians usually only gave one significant diagnosis.  Researchers following a more rigid interview commonly gave multiple diagnoses.  It was proposed that if clinicians followed a more structured DSM approach to diagnosis the reliability rate of diagnoses would improve because clinicians would implement more diagnoses.  The new DSM-IV clinical significance criterion allows for improved correlation between clinician and researcher, but did they forget about the patient?  Establishing a set of criteria to make sure that everyone agrees seems more important than being accurate.  I think that the task force in charge of establishing DSM guidelines should take a better look at why doctors and therapist became doctors and therapists.  It wasn’t to please a set of criteria.  It was to help people in need resolve an issue.  Intent doesn’t remedy conditions.

Within my limited confines I have tried to expose some of the seemingly obvious inaccuracies regarding diagnosis implementation according to DSM-IV criteria.  The DSM is described as a set of guidelines, rather than hard-fast recommendations for diagnosis and care.  This may sound favorable to a reader, but in reality it doesn’t hold true.  Without a diagnosis according to the DSM-IV guides the hospital, clinician or researcher will not get paid by an insurance company and will likely have a governing board investigating their competency to evaluate and treat patients. 

The dilemma of the DSM-IV criteria has reached circles of medical influence.  Mental health professionals are beginning to question the validity of the language expansion of the DSM-IV.  Most mental disorders are accepted as etiological in origin and without external, objective, validating factors (Cain, 2003).  Social and environmentally caused disorders are more difficult to define than biophysical mental disorders like Alzheimer’s disease, Down’s syndrome or even progressive Dementias. Physical, diagnostic testing using x-ray, MRI, CT and Laboratory results in reproducible, objective data that can diagnose a condition without doctor misrepresentation. The reliability of testing imparts validity.  The social and environmental diagnoses of ADHD, anxiety, and personality disorders need more advanced testing methods than are currently employed.  Although psychology deems itself a science, there appears to be an imposed separation between the psychology field and the basic sciences.  This is unfortunate and should be remedied.  I feel that one would support and reinforce the other. 

The National Institute of Mental Health agrees with this approach and stressed the need for cooperation between the basic sciences and the mental health field, particularly developmental neurobiology and behavioral sciences (Hoagwood, 2002).  The NIMH acknowledges the limitations of solid diagnostic criteria within the mental health profession and recommends including biological parameters for future study and analysis.  An example would be the scenario of smoking causing disease.  Smoking has been determined to be a contributing factor to lung cancer.  This causation has been determined using an etiological approach that includes behavioral and biological components.  By testing ADHD, PTSD, and other personality disorders in a similar fashion we might be able to give more definitive criteria to the ‘who and why’ behind mental illness. 

The DSM-IV criteria are actually confining to the mental health profession.  As the DSM becomes more expansive in language criterion it loses the concept of distinct, measurable entities that are so important to condition resolution.  Substance abuse under the new DSM-IV-TR guidelines can be defined as your girlfriend yelling at you about your chemical use and resulting behavior.  But, if the two of your sit down, talk, and come to an agreement about future use and behavior, it is no longer classified as a mental disorder ( Wakefield , 2003).  I wonder how the DSM-IV-TR would classify the young man if his girlfriend sat down, had a drink, and smoked a joint with him?  Would it still be classified as a disruptive mental disorder?

The DSM-IV has provided the mental health field with a set of criteria to establish a diagnosis and begin care to stabilize or resolve mental disorders.  The criteria, however limiting, perform a function that did not exist prior to the implementation of the DSM-I in 1952.  Establishing distinct criteria by using empirical, clinical, and research data has allowed the psychological field to be considered a hard science.  I feel that the implementation of the DSM-IV and DSM-IV-TR places this scientific position at risk.  The categorization of disorders from childhood through adolescence and into adulthood often appears to be rollover diagnoses with minimal attempts at a resolution of the condition.  Even if a condition could be considered resolved by one set of criteria, new criteria allow that same condition to be re-instituted by placing it “in partial remission”.  People classified as mentally impaired seem to be trapped from cradle to grave in the mental health field with little chance for the separation of themselves from a tag-along diagnosis.  The diagnosis is not just a designation of a mental state at any one period of time; it labels the individual.  They must learn to live, work and carry on relationships knowing that they have been labeled as a ‘certain type of person’, rather than an individual with a condition that is progressing toward a resolution.  The confines of the current diagnostic criteria allow for a varied array of symptoms to be placed in one or more categories.  The flexible language that a counselor or therapist can use ‘locks in’ the diagnosis.  Once a diagnosis is established, insurance carriers, other doctors, counselors and therapists may have access to this information.  This strengthens the label established by the diagnosis.  When an employer or a state agency finds out about a diagnosis they may restrict hiring practices or benefit packages.  A normal, stressful, temporary mental state can easily blossom into an 800 lb. gorilla that never goes away.  Instead of helping a patient, the doctor, therapist or counselor might actually be doing harm by implementing a diagnosis.  But, without a diagnosis, the mental health field loses its ‘scientific’ credibility.  This is a double-edged sword that has the sharpest side pointing at the patient.

Having acknowledged the faults of the DSM-IV criteria, I am not sure that I have concrete ideas for fixing the problem.  I feel, however, that criticism without answers is nothing more than a bully pulpit so I will impart a few simple ideas that may have merit.

The DSM-IV and DSM-IV-TR criteria need to be modified and clarified, not disassembled.  The new language that has been implemented in the last two versions of the DSM needs to be either removed completely or restricted to specific conditions.  To say that an adult with no symptomatology from a childhood diagnosis of ADHD is merely “in partial remission” strikes of a never-ending diagnosis that is always reimbursable.  This behavior is likely monetarily driven and not results driven.  Serious re-evaluation is needed.  Re-evaluation is also needed in establishing the significance of a condition.  A mild case of anxiety may be just that.  The expansive language of the DSM-IV allows for this condition to be classified as a mental disorder if the clinician or researcher determines that there is “clinically significant distress or impairment in social, occupational, or other important areas of functioning”.  The diagnosis is not being instituted on the data alone, but also by interpretation.  This leaves much room for deceit, dishonesty, and actually creates the ‘false-positives’ associated with mental health diagnosis.

For the mental health field to solidify their position in the hard sciences they need to become more objective in their assessments.  In my clinic, objectivity is necessary to differentiate if a male patient has simple, acute low back pain or a metastatic bone cancer referred from the prostate.  Testing includes a personal and family history as well as a symptom interview.  Following this there is a physical examination to ‘rule out’ diagnostic possibilities.  If the diagnosis is not firmly established by the examination, x-rays, MRI, CT, and laboratory work-ups might be implemented.  Second opinions and specialist consults are commonly used.  Diagnostic screening continues until the diagnosis is solidly confirmed.  The patient’s life depends on this objective analysis.  They are consulted and kept informed of their status throughout the complete process.  They know that they are a key component to their own recovery, but they also know that there either is or is not the possibility of recovery.

I feel that the mental health field needs to incorporate this type of basic science objectivity into their diagnostic criteria.  By investigating the physical components associated with even temporary mental states the psychology field can solidify their position by first, acknowledging that a condition exists and secondly, determining when it is resolved.  The use of MRI, CT and PET scanning has already proved fruitful in the early diagnoses of schizophrenia due to ventricle size.  It is this use of advanced screening tools that will drive diagnoses in the direction of accuracy.  The demystification of psychology would be financially lucrative to practitioners, researchers, and educational facilities as well.  More people will use mental health services when the diagnosis given is seen as really theirs, rather than what a doctor or therapist gives to them.  These simple steps toward irrefutable objectivity might also increase the number of active mental health practitioners, rather than the trend to use psychology as a springboard into another career.

There is a difficult situation that occurs when objectivity is standardized; the personal flare of the doctor or therapist is minimized and the intent of care is maximized.  The doctor cannot rely on personality or hide behind difficult to understand DSM descriptions.  When objective diagnostic criteria are used to determine that a condition exists, the patient wants to know when they are objectively better as well.  This attitude demands accountability from the doctor or therapist administering care.  The stress placed on the doctor can be minimized by referring to the objective diagnostic data as a predictor of outcomes.  It will actually make the doctor or therapist’s job much easier and less stressful than it likely is now.

A final recommendation that I would have for the mental health profession would be to begin demanding more from patients.  Our society seems to allow everyone to blame their lack of success in one or more areas of life by being a victim.  “Its not my fault”, “I never had a chance”, and “If they hadn’t done that to me…” are just a couple of the many excuses people use justify their situation.  When the doctor becomes a willing accomplice in patient’s situation it does not benefit the patient’s recovery and likely prolongs it.  This may seem like a crass attitude, but it is not.  It is actually an attitude of extreme caring.  When a diagnosis is made based on objective criteria, a behavioral or social disorder will be acknowledged by available data.  The patient that realizes they may not have anything organically wrong with them is likely to take more responsibility for their recovery than the patient who is able to hide behind titles of bipolar and ADHD found in a 4-inch thick manual of disease states. Making the diagnosis of mental disorders should not get easier, but rather, more difficult and exact. 

There has been a social world impact made by fifty years of using DSM criteria.  Many thousands have benefited by consulting with a mental health professional, but I would venture a guess that many have also not benefited from care.  Is this the fault of the therapist?  Possibly.  I would be more inclined to fault the criteria that the therapist was forced to follow.  When the mental health field catches up to traditional medicine in its approach to diagnosis, the influx of people into doctor’s and therapists offices will be staggering.  Who wouldn’t go to see Mary Smith, PhD for an anxiety issue when objective findings could be obtained and a resolution accurately structured.  It would be much like consulting a financial planner; you have questions and they have answers.

The world is becoming smaller as technology and trade increases.  The cultural differences of foreign countries are beginning to influence our cities and nation.  The DSM criterion needs to also reflect these differences to accurately care for a changing population.  Objectivity can accomplish this.  To continue to rewrite and add catchall phrases to the existing DSM criteria will lead to an implosion of mental health credibility.  The doctor, therapist or counselor who can provide a necessary, predictable, results driven service to the public will survive and thrive regardless of insurance coverage or state restrictions for payment of services.  The evolution of the mental health profession is inevitable.  The current trend toward all-inclusive diagnostic coding is not supported by objective, predictable data and will need to be modified.  That direction of modification will follow one of two paths.  The first path follows the current trend of independent, DSM criteria directing the doctor or therapist’s diagnosis.  The second path allows predictable biological and physical tests to be incorporated into the patient’s symptomatic picture.  The objectivity of the testing frees the therapist’s decision-making ability as to causation of the disorder and allows them to focus on correction of the disorder according to the objective data.  Psychology does not need to ‘throw the baby out with the bath water’, but the profession should take a hard look at the validity of the current direction of the DSM criteria.  The mental health profession needs to take steps now to solidify their position of necessity for the next fifty years.             

References

       American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington , DC , American Psychiatric Association, 2000.

       Boschert, S. (2001). ADHD-like cognitive deficits may actually be a learning disorder. Clinical Psychiatry News, 29, 32.

       Caine, E., (2003). Determining causation in Psychiatry. In K. Phillips, M. First, & H. Pincus (Eds.), Advancing DSM: Dilemmas in psychiatric diagnosis, 1-22. Washington , DC : American Psychiatric Association.

       Choudhury, M., Pimentel, S. & Kendell, P. (2003). Childhood anxiety disorders: parent-child (dis)agreements using a structured interview for the DSM-IV. Journal of the Academy of Child and Adolescent Psychiatry, 42, 957.

       Hamstra, B., (1994). How therapists diagnose. New York : St. Martin 's Griffin .

       Hoagwood, K. & Olin, S. (2002). The NIMH blueprint for change report: Research priorities in child and adolescent mental health. Journal of the Academy of Child and Adolescent Psychiatry, 41, 760.

       Hofsta, M., Van Der Ende, J., & Verhulst, C. (2002). Child and adolescent problems predict DSM-IV disorders in adulthood: A 14-year follow-up of a Dutch epidemiological sample. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 182-187.

       Leuzzi, R. & Spandorfer, J. (2000). Some individuals never outgrow ADHD, says DSM-IV. Internal Medicine, 21, 44.

       Lewczyk, C., Garland , A., Hurlburt, M., Gearity, J., & Hough, R. (2003). Comparing DISC-IV and clinician diagnoses among youths receiving public mental health services. Journal of the Academy of Child and Adolescent Psychiatry, 42, 349.

       MacReady, N. (2003). Don’t rely on DSM-IV criteria for adult ADHD: significant impairment common. Clinical Psychiatry News, 31, 35.

       Rohde, L. (2002). ADHD in Brazil : the DSM-IV criteria in a culturally different population. Journal of the Academy of Child and Adolescent Psychiatry, 41, 1131.

       Silverman, W., Saavedra, L. & Pina, A. (2001). Test-retest reliability of anxiety disorders interview schedule for DSM-IV: Child and parent versions. Journal of the Academy of Child and Adolescent Psychiatry, 40, 937.

       Spitzer, R., & Wakefield , J. (1999). DSM-IV diagnostic criterion for clinical significance: Does it help solve the false positives problem? American Journal of Psychiatry, 156, 1856-1864.

       Wakefield , J., & First, M. (2003). Clarifying the distinction between disorder and nondisorder. In K. Phillips, M. First, & H. Pincus (Eds.), Advancing DSM: Dilemmas in psychiatric diagnosis, 23-55. Washington , DC : American Psychiatric Association.

       Zimmerman, M., & Mattia, J. (1999). Differences between clinical and research practices in diagnosing borderline personality disorder. American Journal of Psychiatry, 156, 1570-1574.

Eileen's Corner

This issue is about cookies!  I will include Thumbprints, which is my favorite cookie recipe, and one of Glenn's favorite's, his Grandmother's date cookies.

      Bird Nest Cookies- Thumbprints

1/2 Cup Butter

1/4 Cup Brown Sugar

1 Egg Yolk

1/2 teaspoon Vanilla

1 Cup Flour

1/4 teaspoon Salt

Thoroughly mix together the butter, brown sugar, egg yolk and vanilla.  Sift together the flour and salt, and add it to the butter mixture.

Roll into 1" balls.  Dip in slightly beaten egg white.  Roll in finely chopped nuts.  Place about 1" apart on an ungreased baking sheet.  Bake in a 375 degree oven for 5 minutes and remove.

Quickly press your thumb gently on top of each cookie.  Return to the oven and bake 8 minutes longer.

Cool. Frost each cookie with colored powdered sugar frosting (Red and Green at Christmas, pastels for special occasions.)  Yield: 2 Dozen

             Date-Filled Cookies

1 1/4 Cup Shortening (or Butter)

2 Cups Brown Sugar

2 Eggs

1/2 Cup Warm water

1/2 teaspoon Salt

1 teaspoon Baking soda

4 Cups Flour

1 teaspoon Vanilla

Filling:

1 Package Dates, cut up

1 Cup Water

1/2 Cup Sugar

1 Tablespoon Flour

1/2 teaspoon Vanilla

On the stove, combine and reduce the filling ingredients to a 'thick consistency' and remove (simmer is OK, boil is too hot).

Mix the first 8 ingredients together.  Drop by spoonfuls on a greased cookie sheet.  Make a well in each cookie.  Fill with date filling and top with a little cookie dough.  Bake 15 to 18 minutes at 350 degrees.

I Told You I Was Hurt !

How many times have you heard someone say that they have had a 'whiplash' and questioned if anything was really wrong?  You are not alone if you answered " many times".  The truth is that 'whiplash' can be hard to diagnose if your really not sure what to look for.  Simple pain after an accident is NOT whiplash.

New, objective research from Norway (Kaale, 2003) supports the premise that first, accidents can cause whiplash and second, that ligamentous damage defines whiplash.

As I have explained to patients for many years, x-rays will not show if ligaments have been damaged, unless the appropriate views are taken.  This is because ligaments are soft tissue densities that are not readily visible on x-rays, but you CAN tell if they are properly supporting the spine and if damage has been sustained.  Simple flexion and extension views of the neck can determine ligamentous insult.

This picture points to the neck ligament involvement:

 The tectorial membrane is found directly behind the vertebral body in the neck and in front of the spinal cord.  It helps to support the spine.

The Norway study concluded that the ligament damage sustained to the tectorial membrane was a direct result of trauma and did not just magically appear on its own.  Automobile accident victims had this objective evidence of tearing, while a control group did not.  For patients with chronic, whiplash pain, the culprit may be an old injury that did not heal properly.

Krakenes, J.,  Kaale, B.R., Moen, G., et al. (2003).  MRI of the tectorial and posterior atlanto-occipital membranes in the late stage of whiplash injury. Neuroradiology, 45, 585-91.

If you suffer from acute or chronic neck pain and you are not sure why, the answer may be quite simple.  Some 'whiplash' injuries happen from an automobile accident, while others do not.  Whiplash is a mechanism of trauma and not a place.  Frequent neck pain should be evaluated.  Pain that lasts longer than 2 weeks without going away is a problem and even though the pain may remiss somewhat, the improper healing has begun.  This means that the pain will likely return again because the problem healed wrong.

You may want to go back and review some earlier issues of the newsletters when I talked about mass.  The mass of a vehicle striking you is as important (or more important) as the speed of impact.  The physical damage you sustain occurs before your body moves!  This is 'shearing' of the tissues and this is what causes your resulting injury.  A large vehicle (mass) can do greater damage to your body moving at a slow speed than a smaller vehicle traveling at a higher speed.

Remember,  many of the symptoms resulting from this type of trauma do not show up immediately.  It may take a few days to several weeks for any initial soreness to be replaced by more acute symptoms of pain or numbing or even 'ringing in the ears'.

Pain is Not a Problem. 

It is a Symptom of Something Wrong.

Find out what is wrong.

Fix It!

Crosswords Rule!

I was right!  How often can we make that comment and have it actually be true?  But, this time, I was right!  I have been telling patients for years to do a daily crossword puzzle to keep their brain stimulated.  It stimulates recall and nerve synapse firing.  It forces us to use recall of existing knowledge banks, associate with other information of the puzzle, and use imagery.  I have been validated!

The New England Journal of Medicine recently reported that regular mental exercise decreases the risks of dementia, including Alzheimer's disease.  Something as simple as doing the Sunday crossword reduces the risk of dementia by 7 %.  This is an incredible finding.  It means that we can have some control over our future.  Other activities like playing cards and board games, and playing a musical instruments were also of benefit.  Although exercise is good for us, it did not stimulate the brain in the same manner as a crossword.

Neurology, June 24, 2003

Buy a Paper, Do the Crossword, Thank Yourself!

Hold Your Horses!

I had hoped to bring to you the results of my latest research study in this issue, but I'm afraid that I can't. 

Because of the significance of the findings, it looks like there may be a national publication forthcoming.  I do not want to ruin the chance of a journal publication by shooting my mouth off too soon. that would not be fair to the other two members of the team or the research itself. 

I will publish the results as soon as I can.  It was an interesting study with even more interesting findings!

Attorney General Update

As I said in the introduction, I will be practicing full-time and working part-time at the Attorney General's Office until spring.  This should be fun!  I will keep you updated on the experience!

Have a Great Holiday Season, we will see you in 2004!

Dr. Frisch

I Need Ammunition!

Tis' the Holiday season and we know that means get-togethers with family and friends.  We also know that there is always one (or more) people who think they have all the answers, especially when it comes to your health.  They may berate you for taking care of yourself with regular Chiropractic care and ask you stupid questions that have no real answer.  Unless you are armed with the research that I give you in these newsletters, they may think that they have won some small award for condemning your choice of care.  I am going to give you one of may favorite retorts to people who don't 'believe' in chiropractic.  This is a true story from my clinic!

I was treating a nice middle-aged woman who had been suffering with migraines throughout her life.  She had no relief until seeking chiropractic care at my clinic.  After a few adjustments her headaches went away.  Her husband came with her on one of the visits to find out what kind of 'weird stuff' I was doing to his wife.  He was sitting in the corner of the room with his arms folded looking very stern.  I began to adjust his wife using the Activator Technique.  I could have told you what the first words out of his mouth would be and I would have been right.  "I don't believe in Chiropractic" was all he said.  Not "hello".  Not "thank you for helping my wife".  Only "I don't believe in Chiropractic".  I was sure that he just didn't realize that Chiropractic wasn't a belief system, but I was busy and I didn't feel like dealing with him that morning.  I merely gave him this scenario to ponder:

"Let me ask you something", I said.  "Do you believe in potatoes?"  He looked at me very strangely, so I continued.  "If you suffered with headaches your whole life and I told you to go home, put a potato on your forehead, leave it there for 6 hours and your headaches would go away, when the headaches were gone, would you really care that it was a potato?"  He had such a weird look on his face that I decided not to play with him anymore that day. 

His wife reported later, that after that, he never made that comment again and he actually now understands that chiropractic is about 'structure and function', and not a belief system. 

If you need ammunition, this true potato story always works!