Comments & Controversies

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Is clinical judgment enough dictive value of the clinical evaluation of DECEMBER 2008 to restrict driving? driving fi tness, we encourage physicians In “Driving with : How to to use their clinical judgment to decide assess safety behind the wheel” (Cur- when a patient’s cognitive defi cits or be- rent , December 2008, p. A DOWDEN PUBLICATION • VOL. 7, NO. 12 havioral symptoms preclude safe driv- Driving with 36-48) the authors provided helpful dementia ing. The algorithm emphasizes the role suggestions on how to implement How to assess safety of on-road testing in cases when the driving restrictions. The algorithm, behind the wheel clinician is uncertain. When impairment Words to the wise: 4 secrets however, relies too heavily on costly of successful pharmacotherapy is so severe or obvious that the patient Since Mr. C developed intermittent fever, Is dialectical behavior therapy driving evaluations at the expense of hematuria, and fatigue 2 months ago, the right ‘fi t’ for your patient? clearly is unsafe to drive, in-depth test- his memory has diminished so much PLUS Editorial: Dr. Nasrallah clinical judgment. that he forgets to eat. What’s going on? Should psychiatry list hubris in DSM-V? ing is not needed. For less severe cases,

Out of the Pipeline Although the American Medical Transcranial magnetic stimulation clinicians will need to determine if they Pearls ❙ Support patients coping Association and the National Highway with medical illness have enough information to decide or if

UP TO 18.5 CME CREDITS ¨ Traffi c Safety Administration may not SEE PAGE 65 an on-road assessment is warranted.

feel that a dementia diagnosis is suffi - 0C1_CPSY1208 0C1 December11/17/08 2008 2:24:12 PM Mark Rapoport, MD cient to restrict driving, this opinion is Carla Zucchero Sarracini, BA References not unanimous. In 2000 the American 1. Dubinsky RM, Stein AC, Lyons K. Practice param- Nathan Herrmann, MD Academy of Neurology issued a prac- eter: risk of driving and Alzheimer's disease (an evi- Department of psychiatry ® dence-basedDowden review): report Health of the quality standards Media University of Toronto tice parameter standard that patients subcommittee of the American Academy of Neurol- ogy. Neurology. 2000;54(12):2205-2211. Sunnybrook Health Sciences Centre with a Clinical Dementia Rating of 1 2. Reger MA, Welsh RK, Watson GS, et al. The rela- Toronto, Ontario, Canada should not drive. This ratingCopyright is equiv- tionship between neuropsychological functioning Frank Molnar, MD For andpersonal driving ability in dementia: use a meta-analysis.only alent to probable Alzheimer’s disease Neuropsychology. 2004;18(1):85-93. University of Ottawa Ottawa Health Research Institute 1 3. Auchus AP, Goldstein FC, Green J, et al Unaware- (AD) with mild impairment. ness of cognitive impairments in Alzheimer's dis- Ottawa, Ontario, Canada Furthermore, although the clock- ease. Neuropsychiatry Neuropsychol Behav Neu- rol. 1994;7:25-29. drawing test, visuospatial copying Reference 1. Molnar FJ, Patel A, Marshall SC, et al. Clinical util- tasks, and trail making test B might The authors respond ity of offi ce-based cognitive predictors of fi tness to drive in persons with dementia: a systematic re- not have absolute utility in identify- We agree with Dr. Schoenbachler’s com- view. J Am Geriatr Soc. 2006;54(12):1809-1824. ing those at risk of driving impair- ment that “a prudent clinician may ment, measures of attention and choose to restrict driving privileges visuospatial skills have been found based on bedside examination and to correlate with on-road driving per- clinical impression alone,” and certainly Should dissociative identity formance.2 do not wish readers to disregard the disorder be in DSM-V? Given that visuospatial testing results of patient history, examination, Dr. Henry Nasrallah’s editorial, evaluates an area of cognition that or cognitive evaluation. Indeed, visuo- “Should psychiatry list hubris in is necessary for driving and impair- spatial testing has been shown to have DSM-V?” (From the Editor, Current ment of visuospatial functioning in moderate correlations with driving in Psychiatry, December 2008, p.14-16), AD is signifi cantly correlated with the review that Dr. Schoenbachler cites. touches upon an important subject anosognosia,3 a prudent clinician However, a recent systematic review1 related to psychiatry’s place among may choose to restrict driving privi- highlighted the inconsistency of this medical specialties and the respect—or leges based on bedside examination evidence and reported that only 6 of 11 disrespect—our fi eld gets. I shudder and clinical impression alone. analyses of the relationship between to think that “Excessive Nose Picking” Ben Schoenbachler, MD visuospatial skills and driving showed could be listed in DSM-V with a fancy Assistant professor signifi cant associations. name such as “Rhinotelexomania” or Director, Memory Disorders Program University of Louisville Although our article emphasized “Excessive Biting” with a sexy Louisville, KY the limitations of evidence on the pre- label such as “Onychophagia.” Psy-

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05_CPSY0209 05 1/16/09 9:08:48 AM Comments & Controversies

chiatry has been under attack for be- ponents, nor is it a harmless abstract pharmacologic therapy, and neurolog- ing pseudoscientifi c and not worthy of controversy or just about "opinion" ic abnormalities have been identifi ed.2 the respect that other medical special- or "belief." Patients and families are With DSM-V on the horizon, ties command. There is no need to add harmed by the diagnosis and the prac- classifi cation should be ex- insult to injury. tice of its proponents. panded to include an additional cri- Dissociative identity disorder For economy, I refer readers to the terion of avoidance and/or anxiety (DID) is another controversial diagno- 2-part, 2004 review of DID in the Cana- around speaking situations related to sis that may have been very appealing dian Journal of Psychiatry, which came stuttering.3 By adding this criterion, to Hollywood moviemakers but does to following conclusions: we recognize and can offer treatment the fi eld, patients, and their families • there was no proof that DID to patients who do not have marked a great disservice. Although DID is results from childhood trauma disturbances in fl uency but experience listed in DSM-IV-TR, criterion A—the • DID could not be reliably diag- avoidance and/or anxiety around cer- presence of 2 or more distinct identi- nosed tain feared words or situations. ties or personality states, each with • DID cases in children were al- We also recommend distinguish- its own relatively enduring pattern of most never reported, and ing childhood-onset, developmental perceiving, relating to, and thinking • consistent evidence of blatant stuttering—by far the predominant about the environment and self—is a iatrogenesis appeared in the prac- presentation—on Axis I separate defi nition rather than a useful guide- tice of DID proponents.2,3 from the adult-onset forms. Stuttering line. Who, when, and how does this The DID controversy is not a sym- symptoms acquired as an adult—usu- “presence” become present? What is metrical argument of personal opin- ally through neurologic injury4—are the clinician’s role in the face of the ion vs another or 1 dogma vs another. better coded under Axis III. Stuttering fi rst-person authority? Rather, it is like the Celestial Teapot symptoms also rarely may be mani- In other medical specialties, it parable of Bertrand Russell. An almost festations of conversion or malinger- is recommended—rather strongly impossible belief persists because it ing, and in cases such as this are better encouraged—that the practitioner can’t be proven wrong. classifi ed under these conditions. constantly challenge his or her basic Numan Gharaibeh, MD As the understanding of stutter- assumptions about a possible diag- Principal psychiatrist ing leads toward a more physiologic Western Connecticut Mental Health Network nosis through a methodic process of Danbury, CT etiology, clarifi cation of DSM-V criteria inclusion, exclusion, and hypothesis will ensure that millions of individuals testing. Gullibility, lack of scrutiny, References who stutter will have greater access to 1. Davidson D. Subjective, intersubjective, objective. lack of skepticism, and not having a New York, NY: Oxford University Press; 2001. comprehensive care, including emerg- high index of suspicion are signs of 2. Piper A, Merskey H. The persistence of folly: a criti- ing pharmacologic therapies. cal examination of dissociative identity disorder. poor clinical practice. To use Donald Part I. The excesses of an improbable concept. Can J Gerald A. Maguire, MD, DFAPA Psychiatry. 2004;49(9):592-600. Davidson’s words, the skeptic’s at- Victoria Huang, BA 3. Piper A, Merskey H. The persistence of folly: critical tempt to investigate dissociative phe- examination of dissociative identity disorder. Part C. Scott Huff man, MA II. The defense and decline of multiple personality Department of psychiatry nomena—especially DID—is bound or dissociative identity disorder. Can J Psychiatry. 2004;49(10):678-683. School of medicine to break on the rocks of the fi rst-per- University of California, Irvine son authority.1 The antipsychiatry movement, References 1. Maguire GA, Yu BP, Franklin DL, et al. Alleviating despite its excesses, helped psychiatry Add avoidance/anxiety stuttering with pharmacological interventions. Ex- do some introspection and look at its to DSM-V stuttering criteria pert Opin Pharmacother. 2004;5(7):1565-1571. own excesses. It helped the fi eld evolve With advances in the understanding of 2. Alm PA. Stuttering and the basal ganglia circuits: a critical review of possible relations. J Commun Dis- from pseudoscientifi c psychoana- stuttering and development of phar- ord. 2004;37(4):325-369. lytic traditions to the evidence-based macologic therapies,1 modifi cations to 3. Diagnostic and statistical manual of mental disor- ders. 4th ed, text rev. Washington, DC: American practices of today. The polarizing DID the classifi cation and treatment of this Psychiatric Association; 2000. diagnosis is not only a difference of disorder are indicated. Research has 4. Ludlow CL, Rosenberg J, Salazar A, et al. Site of penetrating brain lesions causing chronic acquired opinion between proponents and op- shown that stuttering improves with stuttering. Ann Neurol. 1987;22(1):60-66.

Current Psychiatry 6 February 2009

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