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.