Opinion ID: 2561809
Heading Depth: 5
Heading Rank: 2

Heading: The State Experts' Failed to Rely on the DSM-IV

Text: ś 56 The DSM-IV is the authoritative tool for diagnosis in the field of mental health; however, Drs. Jeppson and Whitehead stated that the manual was of little or no use to their analysis of Ms. Barzee's case. Dr. Jeppson stated, I am not tied to DSM-IV  When asked about the characteristics of PDNOS, he responded that he had not reviewed that recently. I don't pack [the DSM-IV ] around. When Dr. Whitehead was asked about specific diagnoses and their implications for treatment decisions, he stated that diagnosis has little, if any, ramifications for treatment, despite extensive research cited by the defense experts suggesting that diagnosis and symptoms have significant ramifications for a patient's response to medication. Indeed, Dr. Amador testified that the difference in diagnosis at this particular hearing is relevant to predicting response to antipsychotic medication. The state hospital physicians' dismissal of the standard diagnostic system used in the field of psychiatry is perplexing in light of the important questions they were asked to address by the State in this case. While diagnosis may not be critical to the question of whether medication is medically appropriateâ because for any form of psychosis, drugs will almost undoubtedly be appropriateâ diagnosis is of utmost ,importance for predicting the effect of medication on a particular patient. In this case, the court was not asked to consider the likelihood of any psychotic patient being restored to competency through medication; instead, the court was to decide whether forcible medication was likely to restore Ms. Barzee to competence. I am at a loss to comprehend the State witnesses' disregard of the DSM-IV, an important and integral tool for diagnosis in the mental health arena. ś 57 Not only did the State witnesses disregard a basic tool of their trade, but Dr. Jeppson, without the aid of the DSM-IV, made a puzzling change in Ms. Barzee's diagnosis from delusional disorder to PDNOS. Three of the four witnesses at the Medication Hearing agreed that delusional disorder was a reasonable diagnosis for Ms. Barzee. Dr. Jeppson knew that Ms. Barzee had experienced referential thinking prior to his initial diagnosis of delusional disorder, [17] yet he pointed to no other factor explaining his subsequent change in diagnosis except her continued reports of referential thinking. [18] Although Dr. Jeppson testified that referential thinking was one of many changes influencing his decision, he failed to cite any other factor, and the factor he did identify was not even a change. He stated that he did not believe that referential thinking was part of the symptomology of delusional disorder pursuant to the DSM-IV â which he had not read recentlyâ but if it is, it is certainly a small part. While Dr. Jeppson eventually softened his assertion that referential thinking removes one from the diagnosis of delusional disorder, this assertion was flatly rebutted by other witnesses. Dr. Morris testified that delusional ideas of reference are simply one delusion of the delusional disorder and that the symptom does not remove one from a diagnosis of delusional disorder according to the DSM-IV. Dr. Amador, the co-chair for revising the DSM-IV section on psychotic disorders, stated that referential thinking as exhibited by Ms. Barzeeâ receiving messages from moviesâ did not remove her from the diagnosis of delusional disorder in the DSM-IV. Not surprisingly, the DSM-IV section on delusional disorder states, Ideas of reference (e.g., that random events are of special significance) are common in individuals with [delusional] disorder. Their interpretation of these events is usually consistent with the content of their delusional beliefs. DSM-IV 325-26. Thus, I am skeptical of Dr. Jeppson's change in diagnosis based on factors that apparently do not withstand the scrutiny of other mental health professionals and published professional standards. I am further troubled because the DSM-IV, the standard tool for diagnosing mental illness, appears to have been given little, if any, weight by Drs. Jeppson and Whitehead. Furthermore, in view of the DSM-IV's flat rejection of the notion that ideas of reference are not a symptom of delusional disorder, I find Dr. Jeppson's testimony unpersuasive. [19] ś 58 Equally perplexing is the change after two years of treatment from the more specific diagnosis of delusional disorder to the more general one of PDNOS. [20] Dr. Morris pointed out that there is no evidence that Ms. Barzee's condition is the product of substance abuse or a medical condition, and Dr. Whitehead noted that the chance that a medical condition was causing her symptoms was extremely unlikely. Thus, the remaining diagnoses beneath the umbrella definition of PDNOS, which are available to this particular patient, are schizophrenia and delusional disorder. [21] Only one initial evaluator, Dr. Cohn, suggested that schizophrenia was the appropriate diagnosis; all the other practitioners doubted the existence of symptoms as severe as Dr. Cohn's report suggested. Neither of the State witnesses at the Medication Hearing suggested that. Ms. Barzee met the criteria for schizophrenia or even opined that it might have been an appropriate diagnosis. Thus, while the boundaries between psychotic disorders may at times be fuzzy, according to Dr. Whitehead, the opinions of all the mental health professionals involved in this case persuade me that it is extremely likely that Ms. Barzee suffers from delusional disorder.