Members of PACEsConnection, intimately exposed to the pandemic of interpersonal violence, must be especially sensitive to contemporary medicine’s shortcomings. All of us spend most of the time coping. If we are victims of violence or abuse we search for the path towards personal strength, integrity and resilience. If we are therapists we accumulate strategies and tactics to help rebuild shattered souls—one at a time. Few of us have the time, the energy or the interest to explore larger issues of context, culture, policy and tradition.
This post describes a major shortcoming in traditional medical psychiatry which greatly impairs understanding and treatment of the victims of violence—especially child abuse and neglect. The discussion here should be of interest to all members of PACEsConnection. It details a “structural prejudice” which denies and belittles the effects of interpersonal violence, thus retarding understanding and therapeutic progress. This is a wakeup call for all of us to become involved in influencing policy and culture on the broadest scale.
While the House of Medicine sits proudly on a foundation of science, compassion, and efficacy, its construction has a long history of misdirected efforts, rigid dogmatic traditions, and culturally motivated disrespect for important humane values related to race, ethnicity and class. At the present time our community is being especially harmed by the attitudes and dogmas of medical psychiatry that influence the rest of medicine. For generations, clinical understanding of mental illness has been constrained by the symptom complexes described in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM). In fact, in 2009 the National Institute on Mental Health (NIMH) instituted the Research Domain Criteria (RDoC) framework for mental illness research funding as an alternative to the inadequacies of the DSM model. In RDoC, psychiatric illnesses are not defined as discrete categories, but instead as specific behavioral dysfunctions irrespective of DSM diagnostic categories.
This approach was taken because NIMH recognized two primary weaknesses in the DSM: (1) the same symptoms occur in very different DSM defined disease states; and (2) DSM criteria lack grounding in the underlying biological causes of mental illness. RDoC was intended to provide an improved basis for understanding psychiatric pathophysiology and treatment. This reformulation is extremely important for the study and treatment of child abuse and neglect trauma, because in the intervening dozen years there has been no change in psychiatry’s approach or in the DSM.
The DSM-5 attends to child maltreatment trauma only at the end of the volume after defining the accepted diagnostic categories for various mental illnesses, based on symptom complexes. On page 715, there is a brief section called “Other Conditions That May Be as Focus of Clinical Attention.” It states that the conditions listed there merely affect mental disorders; they are not mental disorders themselves; and they cannot be treated as mental disorders. Thus designated by the DSM-5 coding system, they are not reimbursable by insurance companies. Conditions relegated to this section include Child Physical Abuse, Child Sexual Abuse, Parent-Child Relational Problems, Child Affected by Parental Relationship Distress, Child Psychological Abuse, Spousal Violence, and others. Thus the presence of any of these conditions is rarely specifically coded in a patient’s medical record. This presents a major problem to clinicians who study and treat the effects of child abuse trauma.
We all know adults with a history of abuse who have lived unhappy lives of maladaptive or dysfunctional behaviors that are their symptomatic responses to their trauma rather than a DSM defined mental illness. Seeking psychiatric help, many have been given different formal DSM diagnoses together or in serial over time along with multiple courses of ineffective medications, often complicated by side effects, as their symptoms evolve. Some are dosed with polypharmacy in an attempt to control their behavior without therapeutic benefit. Conversely, some traditional DSM diagnoses, for example, dissociative disorder and borderline personality disorder occur primarily, if not only, in the context of severe child maltreatment trauma. Historically, because of the absence of a DSM category for child maltreatment trauma, certain syndromes, for example, completed or attempted suicide, have been evaluated without attention to a history of child abuse trauma. In other circumstances, for instance, the evaluation of pharmaceutical treatment efficacy for depression or anxiety, the absence of attention to a history of child maltreatment trauma as a confounding or comorbid factor negates the validity of the research.
At the same time, medical psychiatry has placed increasing emphasis on pharmacotherapy and paid little attention to the many nuanced behavioral treatment modalities developed by non-medical therapists. There is good data on how many adults with a history of significant maltreatment turn to drugs or alcohol to manage their distress, but there are no studies of how many alcoholics or heroin addicts have been abused as children. In sum, the DSM paradigm has been a barrier to insight and understanding the mental distress of those who have experienced trauma from abuse or neglect. This impaired perspective impacts all of medical care that generally overlooks the lifelong physical, as well as mental, harms caused by child maltreatment trauma.
Recently, we published in a peer-reviewed professional journal a major paper comprehensively analyzing these problems, as well as pointing out, that abused patients have measurable genetic, genomic, neuro-anatomic, hormonal, and inflammatory changes. We lay out a comprehensive, evidence-based discussion on why a major rethinking and reformulation of the DSM is mandatory. The paper is attached to these introductory comments. Please take the time to read it. (The supplemental essays are material as well.) The PACEs Connection community has a special interest in this paper as it is designed to provide leverage for improving the system and providing better care. Your comments, criticisms, and further insights will be appreciated. I invite, and it is important, for all participants in PACEs Connection to join in to help promote the suggested changes.
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