Our intern gave a really good summary at a clinical meeting this week about an article entitled “Diagnostic Inflation” by Dr. Laura Bastra, PhD and Dr. Allen Frances, MD (1). He gave his talk the title, “When normal is not normal anymore”. He raised concerns about how the American Psychiatric Association’s new Diagnostic and Statistical Manual of Mental Disorders, version 5 (DSM-V) has included what some may consider to be fairly vague diagnoses of human conditions within the realm of normal. A classic example raised today was ‘temper dysregulation disorder with dysphoria’ – is this a new excuse for those with short tempers? I wonder what temper dysregulation disorder with euphoria would look like? In recent months there was also a lot of controversy around the removal in the DSM-V of the bereavement exemption from the diagnostic criteria for major depression, which many have viewed as having the potential for pathologising the normal human grief response.
The article itself looked at the issues associated with over-diagnosis and the over-medicalisation of normality. The authors advised a “Stepped Diagnosis” approach for psychological complaints, with watchful waiting and minimal interventions advised before labeling someone with a potentially stigmatizing mental health condition. It encouraged normalising problems (without minimising their gravity), which I think that thankfully, most of us try to do in our everyday general practice already.
These discussions around over-medicalisation reminded me of the frequent consultations I have with parents and young children where I am providing reassurance, explanations and education about normal developmental stages of life. One bugbear of mine is the term ‘colic’, which means a multitude of different things to different people. I am so grateful for the “Period of Purple Crying” website, which focuses on normalising the period of irritability and excessive crying in an infant’s early life and encourages avoidance of the term “colic”, which implies that there is some pathological process occurring, which is most commonly not the case at all.
The similar theme of a ‘do nothing’ approach was touched upon in a recent article in Australian Family Physician (2), as referenced on Twitter:
There was another tweet only the day before referencing an article from the British Medical Journal (3) along the same lines:
I agree with what Des writes in his article, that “medicine is about comfort and reassurance.” After all, doing nothing aligns rather well with the Hippocratic principle of primum non nocere (first do no harm), which my medical class recited from the Declaration of Geneva at our graduation.
I always thought there was merit in this approach, and this was re-iterated when I read the “bawdy cult classic” novel, “The House of God” (4), and the medical intern protagonist Dr. Roy Basch learns from his senior resident, The Fat Man, the laws of the House of God. He follows The Fat Man’s advice and does nothing to the gomers (patients), and they actually remain in good health. Truth is often stranger than fiction, and I have seen examples of this many times when active treatments are withdrawn from palliative patients nearing the end of life, followed by their miraculous improvement!
However, I believe that there is a difference between ‘doing nothing’ and providing reassurance with watchful waiting. There is a difference between normalising symptoms with vindication about the way that a patient feels, and standing idly by doing nothing. Reassurance and an actively listening ear from a general practitioner are hugely powerful. Arranging appropriate follow up, unless the patient is cynical and assumes you are trying to drum up business, can also be very reassuring to an anxious patient. A lot of the resistance to normalising symptoms in the general practice world, I believe, stems from a need to ‘do something’ and an uncomfortable feeling if there is some uncertainty in a diagnosis. Sometimes we doctors institute treatments because we feel this need to ‘do something’, or we give in to patient pressure for a quick-fix medication, which is often an attempt to treat our own anxieties, rather than a legitimate illness in the patient. But at what cost? No medication or herbal remedy comes without potential side effects. With appropriate reassurance, education and explanation, I find that most patients are willing to accept ‘no treatment’ as a good treatment.
1. Batstra, L and Frances, A. Diagnostic Inflation, Causes and a Suggested cure. The Journal of Nervous and Mental Disease, Volume 200, Number 6, June 2012.
2. Cooke, G and Mitchell, B. A is for aphorism ‘Nothing is sometimes a good remedy’, Australian Family Physician, Volume 42, No.7, July 2013 Pages 507-508
3. Spence, D. The power of doing nothing, BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f4409 (Published 9 July 2013); Cite this as: BMJ 2013;347:f4409
4. Shem, S. The House of God. The Bodly Head Ltd. Great Britain. 1979.