Bon essayons de lancer un debat d'actualite. Que pensez vous de la polemique sur le DSM

[Nicholas Anderson]

http://www.infirmiers.com/actualites/actualites/psychiatrie-la-polemique-sur-le-dsm-continue.html

la parole est a vous....

[vic vic]

salut à tous et toutes,

pour moi, débattre, polémiquer est de l'énergie gaspillée et ça ne m'intéresse pas du tout.


j'ai beuaocup milité, je continue mais à ma manière et actuellement, j'ai d'autres centres d'intérêts qui ont, chacun, bcp de retard.

donc, pas intéressée du tout, v.

[Nicholas Anderson]

Vic
Je suis assez d'accord sur le fond de ta pensée.
MAIS
A/ Je voulais que si débat il y avait il ne soit pas modéré/censure et qu'il ne soit pas dit (meme "ordonne") : "ne parlez las au journalistes" bien au contraire, il faut parler a la presse, la mettre de notre cote
B/ le débat a avoir n'est pas sur le DSM mais avec Corcos qui dit des conneries sur la Ritaline au UT de 20 heures sur France 2.
Et ce dans le but de faire évoluer l'opinion publique,

Sinon, je respecte que tu aies d'autres centres d’intérêts..C'est important , J'en ai aussi dont ma moldue (que j'appelle "ma petite Ritaline" car elle me rappelle de me laver les mains, de prendre mes lunettes etc :) )

N

[Nicholas Anderson]

En fait, IMHO, le DSM, meme si il a son utilite, c'est un peu un bazooka cote diagnostic

Il faut debattre de la semiologie fine du disgnostic differentiel TDAH vs Bipolaire vs Borderline 

Ex ce qu'êcrit l'excellent Dr Dodson :

Excerpts from my 2007 correspondence with Dr Bill Dodson (Please do mention his name)

Dear Dr. Anderson,

I apologize for taking so long to get back to you but I wanted to take the time to respond to your

email in the depth it requires. The subject line of your two email contacts was so dramatic that I

tended toward caution before I responded.

Your email touches on a number of factors to which I have found it necessary to devote the better

part of a chapter in my new book. As you point out, the problems come from

1. imprecision in diagnosis. Part of this is just the sloppiness of which the mental health

profession has been accused for years and part is from the time constraints of managed care in

which the patient gets 30 minutes to make the diagnosis. When the examiner will only be

reimbursed for 30 minutes there is the short sighted tendency to cut corners.if the patient says "I'm

depressed" they go on an antidepressant usually without taking the really close history that it takes

to differentiate subtly different conditions.

2. the fact that most training programs not, even now, offer any training on ADHD at any age,

and

3. that we tend to recognize the things that we already know and, hence, see mood disorders

with which we feel comfortable when it really might be ADHD (about which most physicians are

functionally illiterate. Here we see the misuse of the terms "NOS" and "variant" when people really

mean that they can't shoe horn what they hear from the patient into the convenient boxes they

picked up in their residencies.

Four conditions must be distinguished from one another and from any

combination of the four.

1. ADHD

2. Bipolar Mood Disorder and its "variants"

3. Borderline Personality Disorder

4. Premenstrual Dysphoric Disorder

Overlap of symptoms is built into our nomenclature. The DSM IV has 295 separately named

conditions but only 167 symptoms. Consequently, it is often difficult to tease apart clinical histories

to arrive at an accurate diagnosis or set of co-existing conditions. Many psychiatric patients do not

have just one disorder. In a study of adults at the time they were diagnosed with ADHD it was

found that 41 per cent had another active axis I disorder. Thirty-eight percent, in other words

virtually all of that 41 percent, had two or more active axis I diagnoses. Coexisting conditions are

common and a thorough history must be taken during the initial evaluation to screen for a wide

variety of conditions.

To complicate accurate diagnosis even more, John Ratey points out that the vast majority of people

with ADHD have what he unfortunately called dyslexithymia. If you're at Harvard you have to put

things into Greek rather than saying that people with ADHD "use the wrong words for feelings."

My patients do not use words in the same way that I do and I have to take pains to slow down,

listen, and explore each person's unique use of words to describe abstract things like emotional

states. For instance, I suspect that the reported co-morbidity of ADHD and anxiety disorders is a

gross exaggeration. To be sure, about 40% of my adult ADHD patients come in reporting

"anxiety." When I ask them, however, to tell me more about their "baseless apprehensive fear" I

From @mail correpondance Dr Anderson & Dr Dodson (2007)

p 1 of4

usually get a very confused response."I never said I was afraid." More probing commonly brings

out that they are describing a lifelong state in which they are always tense, driven, can't slow down,

can't relax, and have a constant worry that they've missed or forgotten something. This is the

description of the somatic experience of hyperactivity not anxiety. A good portion of the initial

therapy sessions is my trying to understand how this unique individual uses language to describe

and get a handle on his or her emotional life. Poor communication leads to inaccurate diagnosis

which leads in turn to incorrect and ineffective treatment.

Adults with ADHD report that emotional instability is perhaps their most disruptive and impairing

symptom. The second most commonly endorsed feature on our adult ADHD checklist states "For

your entire life have you been much more sensitive than other people you know to rejection teasing,

criticism and frustration." This definition was lifted from the old Psychiatric Glossary term of

"rejection sensitive dysphoria." Fully 98 percent of adults with ADHD report exquisite sensitivity

to the perception of rejection, criticism, and teasing. This catastrophic emotional reaction is

often internalized with an instantaneous full depressive syndrome complete with suicidal ideation.

Many adults describe a physical stabbing pain in the chest. Other adults externalize the dysphoria in

fits of uncontrollable verbal rage at the person or thing that wounded them or that they perceive to

be the source of the rejection or humiliation. The interpersonal nature of the trigger and the sudden

overpowering of Ego defenses often lead to a mis diagnosis of borderline personality disorder

(BPD). Unfortunately, it usually takes extensive experience with a given patient to fully catalog the

presence or absence of the ego structures and object relations necessary to distinguish ADHD from

BPD and from the two conditions together.

Historically treatment has focused on the similarity of this mood lability with this much older

concept of rejection sensitive (or hysteroid) dysphoria. Although nothing has been published in the

last 15 years on these dysphorias, Wender originally used the MAO-I's --with fairly good results. In

an unpublished report of 227 adults with ADHD and severe rejection sensitivity all the patients

reported significant improvement in mood stability and rejection sensitivity while taking (which

has significant inhibition of monamine oxidase B as one of its many neurochemical activities). It is

unknown whether similar results will be obtained with methylphenidate.

Women with ADHD appear to have premenstrual disorder (PMS, Premenstrual Dysphoric Disorder)

more frequently and more severely then do women who do not have ADHD. Research protocols

currently require four out of five of the following criteria for a diagnosis of ADHD associated with

PMS:

highly regular and predictable menstrual cycle

highly predictable onset of dysphoric symptoms (ex. Always X number of days prior to menstrual

flow)

abrupt onset of dysphoric symptoms (the slang calls it a "ping")

abrupt offset of dysphoric symptoms

offset of symptoms simultaneous with the beginning of menstrual flow

Many women with co morbid PMS find it impossible to adjust stimulant class medications or report

that the medications don't work at all during their premenstrual time. Patricia Quinn knows more

about this than anyone else. Her thought is that the mood lability and lack of medication efficacy

have the same cause .low estrogen .since getting the estrogen level back up above 150 pg/ml

relieves all of these symptoms

From @mail correpondance Dr Anderson & Dr Dodson (2007)

p 2 of4

ADHD and BMD share 14 features in common and the recent National Co morbidity Survey

Replication found that 19% of adults with ADHD also met DSM IV criteria for BMD. There is

considerable co morbid overlap of the two disorders.

Research by Wilens et al. at Harvard has shown that the two conditions cannot be separated

accurately on the basis of the ADHD symptom set alone. It is the diagnostic criteria for cyclic mood

disorders that separate ADHD from Bipolar.only bipolar looks like bipolar. By diagnostic

definition the moods of a mood disorder "come out of the blue" without a triggering event

and "have taken on a life of their own, separate from the events of a person's life and out side

of their conscious will and control." The mood shifts are gradual.

Rapid cycling BMD is defined as

> 4 shifts in a 12 month period. Even ultra-rapid cycling bipolars take hours to days for their

moods to shift completely. Unlike people with ADHD, rapid cyclers are usually in a mixed state

and are profoundly impaired by their mood dyscontrol.

In contrast, most people with ADHD do not recall any episodes of mood that were

untriggered. In virtually every case there was .

1. a proximate trigger,

2. the mood matched the trigger (mood congruence), and

3. the mood shift was instantaneous.

In other words, the mood shifts were normal in every way except intensity. This is completely

consistent with ADHD alone and NOT with the comorbidity of ADHD plus Bipolar Mood Disorder.

Nonetheless, ADHD and bipolar mood disorder can be distinguished from one another on the basis

of six factors:

1) Age of onset: ADHD symptoms are usually evident early in childhood

and are consistently present lifelong. While BMD can be present in

prepubertal children the mean age at diagnosis in the U.S. is 26 years

of age (although it is common in hindsight to see mood instability

back to latte adolescence).

2) Consistency of impairment and symptoms: ADHD is always present.

BMD comes in episodes that ultimately remit to more or less normal,

euthymic mood levels commonly during the summer months in the Northern

hemisphere.

3) Triggered mood instability: People with ADHD are

passionate people who have strong emotional reactions to the events of

their lives. It is precisely this clear triggering of mood shifts,

however, that

distinguishes ADHD from the mood shifts of BMD that come and go

without any connection to life events.

4) Rapidity of mood shifts: The mood shifts of ADHD are triggered and

are almost always experienced as being instantaneous complete shifts

from one state to another. Typically, they are described as "crashes"

From @mail correpondance Dr Anderson & Dr Dodson (2007)

p 3 of4

or "snaps" which emphasize this sudden quality. By contrast, the

untriggered mood shifts of BMD take hours or days to move from one

state to another. The rapid cycling designation requires only four

shifts of mood in a 12 month period.

5) Duration of mood shifts: People with ADHD report that their moods

shift rapidly according to what's going on their lives. The response

to severe losses and rejections may last weeks but typically is much

shorter and is usually measured in hours. The mood shifts of BMD are

usually sustained and the DSM requires the abnormal mood to be

continuously present for more than two weeks in order to rise to a

mood disorder designation. For instance, to get the designation of a

rapid cycling bipolar disorder the person need only experience four

mood shifts from high to low or low to high in a twelve-month period

of time. Many persons with ADHD experience that many mood shifts in a

single day.

6) Family history: Both disorders run and families but people with BMD

usually have a family history of BMD while individuals with ADHD have

a family tree with multiple cases of ADHD........

This may be a lot more than you wanted but it really is this

complicated. I hope that you find it helpful in what seems like a very

long process of figuring out your life and why it has been so hard.

Warm regards,

Bill Dodson, M.D.

William W. Dodson, M.D.

Board Certified in Psychiatry

Specializing in Adult ADHD

Colorado

From @mail correpondance Dr Anderson & Dr Dodson (2007)

p 4 of4