Danger,
Distress, Dysfunction, Deterioration, Decision-Making
Since the first time I was ever
expected to detain or treat a patient against his or her will, I have
considered and reconsidered the question of “What criteria should I use to
determine WHEN I need to do something that affects another person’s
life, especially if what I am doing contributes to someone being held against
their will?” I ultimately realized that
my duty of when to act as a psychiatrist boils down to five simple
criteria: danger, distress,
dysfunction, deterioration, and/or decision-making incapacity. These five considerations, all of which
begin with “D,” have become my mantra, my “Five Ds of Psychiatry.” If I don’t believe that one or more of these
five criteria is met, I would conclude that there is no crisis, and consequently,
there is perhaps no need to do anything at all. Although making this determination seems simple enough, I have
discovered how much disagreement there is (even among the so-called “experts”)
on what actually constitutes “danger,” “distress,” “dysfunction,”
“deterioration,” or “decision-making incapacity.”
General questions to consider during
psychiatric assessments include: “Is
psychosis always dangerous?” “Should
psychosis always be treated?” “Whose
distress or dysfunction are we talking about?…..that of the patient or that of
those around them?” “Can value
judgments cause differences in what is labeled ‘dysfunction’?” For example, I once assessed a patient in
the emergency room who had schizoaffective disorder. This particular patient had the experience of hearing both
“angel” and “devil” voices. He had
discovered that, if he took too much Zyprexa (15mg) per day, both his “angelic”
and “devilish” voices were eliminated.
However, if he only took 7.5 mg of Zyprexa per day, only the “devilish”
voices were eliminated, while he sill heard the “angelic” voices. He told me that he preferred to be able to
hear the “angelic” voices. At times
when he was hearing only the “angelic” voices, he did not feel distress, and
did not put himself or anyone else in danger.
Thus, even though hearing “angelic” voices might be considered by some
psychiatrists as a “psychosis” that needs treating, the patient in this example
does not meet any of the 5-Ds criteria.
Thus, I concluded that it was perfectly reasonable to maintain him at
the 7.5 mg level of Zyprexa.