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In the clinic: First, do no harm.

In the Clinic. Today’s post launches another regular feature of my blog. The clinic is where “the rubber meets the road” – care of the individual patient, in the real world. Studies and statistics are important, but in the final analysis, everything comes down to the treatment of individual patients, one at a time. “In the Clinic” will be a potpourri of clinical experiences, clinical questions, and clinical pearls I have gathered over 30 years of practice. I have decided to inaugurate this column with a series of posts about the DSM-5.

Figure: The Staff of Aesculapius – the ancient Greek symbol of the healing arts. (The Roman version, the caduceus, has two snakes, entwined, DNA-like around each other.)

“Primum non nocere” – First, do no harm. This is the cardinal principal of Medicine, drummed into every medical student long before they touch their first patient. Hippocrates, the ancient Greek physician who gave us the Hippocratic Oath (“Whatever houses I may visit, I will come for the benefit of the sick…”), is often credited with this dictum as well, although the version that comes down to us across the centuries is in Latin, rather than Greek.

Today we know more about the biology of health and disease than Hippocrates could have imagined. Nevertheless, the guiding principle “Do no harm” remains unshaken. Scientific analysis of the merits of any form of treatment always comes back to the “Risk-Benefit ratio”, i.e. what is the balance between the potential for doing harm, versus the potential for doing good? If you can’t be reasonably certain that the potential benefits accruing from intervening will outweigh the potential harm, then leave well enough alone. Don’t succumb to the temptation to “just do something.” You could make a difficult situation even worse.

Unfortunately, the American Psychiatric Association may have abandoned this principle, at least insofar as its treatment of Autism Spectrum Disorder in the DSM-5 is concerned.

I cannot say for sure that the changes in the DSM-5 actually will do harm. But there is ample evidence of their potential to do harm, and scant evidence of their potential to benefit children or adults with ASD. In the parlance of modern Medicine, the Risk:Benefit ratio does not lean in the direction of the DSM-5.

“Harm,” in this instance, means pushing some people with ASD out of the boat (or, not letting them into the boat in the first place). We live in a society where – rightly or wrongly – services are tied to having a diagnosis. This tendency has become especially pronounced within the educational system, where huge sums of money are earmarked exclusively for children on the autism spectrum.

“Well, it’s only a small number of individuals at the margins, who may fail to qualify for an initial diagnosis, or who may lose their diagnosis.” So goes the counter-argument. But here’s the catch: The children and adults who are at greatest risk for losing a diagnosis are the highest functioning ones – the ones for whom services might spell the difference between “graduating to the sofa” after high school, versus going on to college, or trade school, or into the workforce. (Fred Volkmar, MD, Chair of the Child Study Center at Yale University, has reviewed the research evidence on this point here.)

Teens and young adults with mild atypicality have the potential to make it in the real world, with support. But without support, they can become isolated, depressed, and disaffected. At the very least, this leads to waste of talent. At the worst, unaddressed social and mental health issues can lead to catastrophic consequences. The DSM-5 carries the potential to pull the rug out from under some portion of this population. So much for the “Risk” side of the DSM-5. Where are the equally compelling potential benefits? In fact, the Risk:Benefit ratio of the DSM-5 (at least insofar as ASD is concerned) seems to be almost entirely risk, with little or no potential benefit. This is contrary to the spirit of “First, do no harm.”

Next time, we will begin to pick apart the specific attributes of the DSM-5 that are so problematic.


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