I believe in diagnosis but the DSM is just a door-stop

About a month ago, the Applied Psychology Department of Canterbury Christ Church University asked me to write a guest piece for their blog. After much rumination and multiple re-hashes, it was posted earlier this week. They usually hold a fairly anti-diagnosis, pro-lived experience position, so I was glad they agreed to let me discuss how I think that in the real world, diagnosis isn’t all about DSM-5 and symptom counting. The original piece, complete with a thoughtful string of comments, can be found here.

The heat from the release of the “psychiatric Bible” (DSM-5) is thankfully simmering down. In recent months, you couldn’t throw a metaphorical brick on Twitter without hitting someone who had a strong opinion and wasn’t shy of sharing it. I found this debate stimulating, frustrating and eventually repetitive. Rarely however, did I find it clinically relevant.

There may be a number of reasons for this. For one thing, DSM-5 is an American book; we use a different classification (ICD-10) here in Britain. Also, I currently work in an area of psychiatry that deals heavily with an illness that DSM doesn’t have a definitive role in, namely dementia. But mostly, I wasn’t too bothered because, to the probable surprise of non-medics and the public, most psychiatrists don’t really care about the finer points of classification.

It’s not that psychiatrists don’t believe in the merits of diagnosis. Both I, and the vast majority of colleagues I’ve encountered, see large benefits in labelling people. I think it provides a useful conceptual framework, a way of thinking about someone, helping someone, and researching common types of suffering. And it’s not that I and many colleagues are quacks, giving whatever wild and personally favoured diagnosis we feel like, without thought for inter-rater reliability. I’m aware of the controversies about diagnosis, and the harms that it causes when we get it wrong. However, these are not the reason why many psychiatrists don’t have a large amount of time for DSM.

No, the reason it doesn’t get much attention from us is because most diagnoses are pretty clear. Patients usually fit quite neatly into the large, intuitive boxes for mental distress that we’ve already had for years. If you’re really unhappy, we call it depression. If you’re really happy, we call it mania. If you’re hearing voices, are paranoid and believe utterly strange things, we call it schizophrenia. These are the broad descriptions that we see standing out in our patients, and it’s these that we use in our day to day careers. Whatever tweaks are made to the classification of things like depression aren’t going to change anything. Really sad people will still be depressed.

The small print doesn’t seem useful to us a lot of the time. ICD-10 states that to have a moderate depressive episode, you need to have at least two key symptoms (low mood, loss of interest and enjoyment, and increased fatigability) plus at least three other symptoms (loss of appetite, poor sleep etc) but to have a severe depressive episode, you must have all three key symptoms and at least four others.

This clearly isn’t how depression works in the real world, and psychiatrists, who are more interested in the amount of suffering than the number of symptoms, recognise this. If a patient feels so bad they might try to kill themselves, they’re admitted to hospital whether the book says “moderate” or “severe”. If they’re suffering so much they might lose their friends or marriage, we’d advise an antidepressant regardless of their ICD-10 code. This is a very different thing, however, to arguing that a diagnosis is useless and unreliable, or that depression isn’t “real”.

The endless media reports of psychiatrists ‘labelling grief as mental illness’ were frustrating for me. I think the Daily Mail believes we’ve started picketing funeral homes, with anti-depressants in hand. The truth of the matter is that the expanded definition of depression (which makes it possible to diagnose depression within 2 months of the loss of a loved one) changes nothing in our clinical practice. If you were suffering enough to need drugs before, you still will be. GPs won’t suddenly send us vast swathes of bewildered people who now fit slightly inside DSM criteria for treatment.

Being less reliant on strict classification has both good and bad consequences. It allows us to cast aside our textbooks to see the person, while still maintaining a workable overarching structure with which to conceptualise their distress. It hopefully makes things more personable for the patient, who is told he has bipolar disorder and he’s currently manic, not that he has ‘F31.1: Bipolar affective disorder, current episode manic without psychotic symptoms’.

But we don’t use this simple, loose method of diagnosing all the time. Many specialist services, who deal with problems like autism and ADHD find it useful to stick closely to the classification, usually because it is well grounded in research and useful in deciding whether someone truly does have the disorder or not. Likewise, researchers will classify their participants tightly, so we can all tell who they’ve been studying.

And yes, sometimes flicking through ICD-10 has helped me. I remember one young man who puzzled with his strange behaviour, which included barking at the moon with a bowl on his head and describing the vibrations in parts of his brain. Despite his actions, he seemed quite attached to reality. It wasn’t until I reacquainted myself with the criteria for schizotypal personality disorder that I began to understand him better.

So, although the finer points of diagnostic classification can be useful, the vast majority of the time psychiatrists have far more pressing concerns than which subgroup of a subgroup someone falls into, like how bad someone is feeling and whether they need help.

The fact that the public thinks we sit in our offices, thumbing through DSM, ticking off symptoms to reach a diagnosis, is both hilarious and worrying.

ICD-10s are propping open doors, steadying wonky tables and gathering fine coverings of dust worldwide. The assertion that we’re devoted to these tomes as our ‘Bibles’ is just plain nonsense.

What the hell is a psychiatrist anyway?

So here’s my first blog post. After months of threatening my Twitter followers with a literary crime, I’ve finally done it. I warned you I would.

I want to write about things that are relevant to patients and the public, so I’d love to hear from you if you have any ideas.

For my first post, I’ve chosen to write about something that seems simple, but that in my experience seems not to be obvious to the people that matter; patients. I want to explain what a psychiatrist actually is. What we actually do all day, what the titles on our name badges mean and what our training involves.

So here we go.

Firstly, and to the astonished bafflement of many people, psychiatrists are doctors. In very simple terms, we are doctors that specialise in treating mental illnesses. It’s actually a bit more complex than that, because we sometimes treat “brain diseases” like dementia, but basically, that’s as good a definition as I’ve ever come up with. We tend to see things in a “you’re ill, you need treatment” kind of way, though what “illness” and  “treatment” mean is misunderstood a lot of the time. For me and for most psychiatrists, “illness” is just a byword for mental suffering, and “treatment” involves psychotherapy and social support just as much as medications. A mental illness has to take place as least partly in our brains, because that’s where our minds live, and prescribing medication is what we’re best at (because of our medical training) but a good psychiatrist will see social and psychological treatments as equally important parts of helping someone heal.

A psychologist, on the other hand, is trained in psychology, which is the scientific study of human thought and behaviour. They sat through lectures on topics like “memory”, “personality” and “language” at university. Many go into research in these areas, and many teach. But many are interested in what happens when unhelpful thoughts and behaviours become a source of stress for a person, and how we can help. These are called clinical psychologists and they work with patients to investigate and change the way they think and act, usually by forms of therapy like CBT. Beware: psychologists can get PhDs or other similar qualifications, and then they can be called doctor too, which can be confusing.

All psychiatrists went to medical school for around 5 years, just like all surgeons did, all GPs did and all cardiologists did. We sat through infinite lectures on genetics, embryology, physiology, anatomy, and histology. We lurked on hospital wards practising our cardiovascular and abdominal examination techniques on unsuspecting old ladies, vacantly watched operations with no idea what any of the yellow bits of flesh were, and crammed round the clock for brutal exams. We honed our pub crawl skills to near perfection (I have the mental and physical scars to prove it) and worked up overdrafts so big you’d need an oxygen supply to climb them.

After qualifying as doctors, we all spent at least 2 years working in hospitals, rotating round a series of 4-month-long jobs in medical specialities like surgery, ENT or gynaecology. The first year is called “F1” (Foundation Year 1) and the second year is called “F2” (Foundation Year 2). My dad, a man of fewer words and a different trade, called this my “apprenticeship”.

The purpose of the Foundation years is to push you to the brink of mental breakdown and keep you there. Your job, whether you’re working on a surgical ward, a medical ward, A+E, or somewhere else, is to do all the legwork for the more senior doctors. Blood tests, ordering scans, rewriting drug charts, clerking in new patients, seeing emergencies and writing discharge letters are the bulk of your work. You get in early, you stay late, and you get very few days off. Using the toilet becomes your break time, lunch becomes a myth and sleeping is a decadent sin. But you learn how to cope under pressure, how to make decisions, and how to organise yourself.

If you survive your Foundation years, you’re asked to choose which single speciality you’d like to train in further. Some (the strange, twisted few) choose psychiatry.

The first three years of psychiatry training are called CT1, CT2 and CT3 (CT stands for Core Training). These years used to be referred to as the SHO (Senior House Officer) years, until the terminology changed in 2007 to make things “easier”. Some people still use the term SHO (like my Twitter name). The table below should make things clearer.

Years after qualifying Old terminology New terminology
1 House Officer (HO) Foundation Year 1 (F1)
2 Senior House Officer (SHO) Foundation Year 2 (F2)
3 Core Training Year 1 (CT1)
4 Core Training Year 2 (CT2)
5 Core Training Year 3 (CT3)
6 Registrar Speciality Training Year 4 (ST4)
7 Speciality Training Year 5 (ST5)
8 Speciality Training Year 6 (ST6)
9 Consultant Consultant

The 3 Core Training years involve rotating around at least 2 adult psychiatry jobs, and at least one child and one old age psychiatry job. Each job lasts 6 months. The idea is to build up a solid base of knowledge in all forms of psychiatry. As a CT1 I’ve worked on an inpatient adult ward and in an old age community team. I’m still the most junior doctor on my team, which is frustrating. It means I still have to do all the menial jobs like doing ECGs, taking blood tests, rewriting drug charts and sorting out any minor problems the nurses might ring me about. I also type notes about what’s being said during the ward rounds; a job I find difficult and annoying because it distracts me from really listening to what’s said. However, we do get to spend a fair bit of time either on the ward talking to our patients, or teaching students.

We’re also on a big rota for on-call shifts. These are changeable in the severity of the workload, but are usually somewhere between difficult and dangerously impossible. Either in the evening, at night or at the weekend, when every other doctor is at home, you’re given a phone and you’re the first port of call if the nurses have any problems anywhere in the hospital. Anything from dealing with a physical health problem, to clerking in a new admission, to getting a taxi to A+E to see a referral there, it’s the job of the CT doctor.

I spend about 80% of my time on call running from ward to ward and 20% of the time laughing ironically because I know I just can’t do the job as well as I want to, because I’m so busy. I’m really sorry if any patients or ex-patients are reading this and have had bad experiences waiting for the on-call doctor to arrive. Trust me, it’s not that we’ve got our feet up somewhere watching the football; we’re probably drowning in jobs on another ward somewhere.

As part of our CT jobs, we get taught a lot. We don’t just learn about medications, the Mental Health Act and classifications of illnesses, but about psychology, psychotherapy, the history of psychiatry, sociology and research techniques. It surprises a lot of people to find this out; I really wish it didn’t. We tend to be pretty holistic, well rounded people most of the time, not the drug pushing robots people take us for.

During our CT years, we have to take exams to prove we’re good enough to progress to our next stage of training. Currently we have to do 3 written exams and a practical exam (which is mostly communication skills), and if we pass them all first time, in total they’ll cost £1660. When you add that to the £400 a year it costs us just to stay registered with the GMC, it’s quite a bit of money for a young person to be shelling out.

If we make it through the CT years, we get to become a registrar (or “SpR”)  and do our Specialty Training (ST), becoming even more specialised in one of a choice of 6 types of psychiatry:

  • General Adult
  • Old Age
  • Child and Adolescent
  • Psychotherapy
  • Forensic
  • Learning Disability

SpRs have a bit more clout. They don’t have to cope with so many of the little jobs from the ward anymore, so they’re free to deal with bigger problems, like running clinics and ward rounds (either with or without the consultant). They’re also senior enough to section people, and spend a lot of their on-calls either driving around doing this or being phoned by me whining about how busy I am.

And if you make it through all that, without deciding that you’d rather work in the city, become a GP, open a café in Brighton or emigrate to New Zealand, you can be a consultant. If you can find a job.

I really hope that makes the water a little bit less muddy for anyone who has been wondering what the hell psychiatrists actually are. If anything remains hazy, let me know.  

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