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and more dsm-v controversy…

In Child/Adolescent Psychology, DSM-V, Neuropsychology, Psychiatry, School Psychology on Tuesday, 21 May 2013 at 06:48

DSM-V: Past Imperfect

By: Nassir Ghaemi, MD, MPH

 Thoughts on a New DSM

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is here. We might as well pretend that Ronald Reagan is still president. Radical changes were made, with limited scientific evidence, when DSM-III was published in 1980 (the year Reagan was elected); even the tiniest changes, with great scientific evidence, are now the subject of outrage.

For me, DSM-5 is a disappointment. I take no pleasure in making this judgment. I wish I could say that DSM revisions are increasingly scientific and getting us closer to truths. But this simply hasn’t happened.

DSM-5 is a disappointment for me not because it is much different from DSM-IV, but because it is so similar. Almost 2 decades after the fourth revision in 1994, despite thousands of research studies on psychiatric conditions, our profession hardly can bring itself to change anything of importance. The radical bipolar/major depressive disorder (MDD) dichotomy is unchanged and untouchable — the third rail of US psychiatry — despite numerous studies casting doubt on the validity of the MDD definition and providing support for broader definitions of bipolar disorder.

The personality disorder concept was nothing but the description of psychoanalytic speculations in 1980. It has remained basically unchanged, despite little research evidence of validity. Personality traits, one of the most well-proven facts in psychology, were recommended by the DSM-5 task force but vetoed by the American Psychiatric Association Board of Trustees. Science was rejected; psychoanalytic tradition was not.

Clinicians may have assumed that we have scientific validity for most of the approximately 400 diagnoses in DSM-5; we have hardly any validity data for the vast majority of those diagnoses, and we have notable validity evidence for numerous concepts that are excluded.

The claim in the Reagan presidency was that DSM would provide reliability; we could agree on definitions. Then, we would do more research so that definitions would evolve toward better validity. Reliability would lead to validity.

When Bill Clinton was president and DSM-IV was published in 1994, a change happened: DSM became an end in itself. The DSM-IV leadership explicitly stated that unless a very high bar of scientific evidence was reached, no changes were allowed. The bar kept being moved higher and higher for science, and lower and lower for politics. The DSM-IV leadership called it “pragmatism”: DSM changes were made on the basis of what that leadership thought was best for patients, they said, and for the profession.

Reliability had become an end in itself; validity no longer mattered because, in a species of extreme social constructionism, the DSM-IV leadership saw the nosology as a way to influence practice, not as a way to discover causes of and treatments for mental illnesses. (They didn’t bother with the question of how you could practice well if you didn’t find out the causes and treatments of illnesses.)

There were hopes that DSM-5 would be different, with scientifically based changes. But a major backlash came: The DSM-IV leadership opposed changes on “pragmatic” grounds, and many in the larger public criticized DSM on social constructionist grounds, as just a means for psychiatrists to make money and influence people. Major changes became minor, and even the minor ones were often dropped to an appendix for further research, which is likely to be ignored.

After 2 decades of being a loyal follower of DSM, the debates of recent years led me to make a sad but definite conclusion: DSM has caused stagnation in psychiatry. If DSM categories are devised primarily because professional leaders want to achieve some clinical or even economic goals, there is no reason why nature should play along. By being “pragmatic” and not scientific, DSM has doomed biological and pharmacologic research in psychiatry to failure for 2 generations.

Now I see a generational change. The leaders of the DSM-III, -IV, and -5 workgroups are often literally the same people, representatives of the 1970’s/1980’s generation in psychiatry. Some of us in later generations do not venerate DSM as the bible of psychiatry, as it’s often called; we instead question it as theology instead of science. Recently, the leadership of the National Institute of Mental Health (NIMH) reached the same conclusion and stated it forcefully: DSM criteria are not scientifically valid, and patients deserve better.

DSM-5 is out, and clinicians will use it, but unfortunately it represents a failed past. Those of us who grew up in that past, and have seen how it has led us to stand still, are inclined to agree with the NIMH that our future deserves to be different.

Retrieved from: http://www.medscape.com/viewarticle/804102?src=nl_topic&uac=184795PG

Use DSM-5 ‘Cautiously, If at All,’ DSM-IV Chair Advises

By: Pam Harrison

On the eve of the official launch of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Allen Frances, MD, chair of the DSM-IV Task Force and one of the new manual’s staunchest critics, is advising physicians to use the DSM-5 “cautiously, if at all.”

“Psychiatric diagnosis is facing a renewed crisis of confidence caused by diagnostic inflation,” Dr. Frances, Duke University, Durham, North Carolina, writes in a new commentary published online May 17 in the Annals of Internal Medicine.

Unlike the DSM-IV, which held the line against diagnostic inflation, he states, “The DSM-5, the recently published fifth edition of the diagnostic manual, ignored this risk and introduced several high-prevalence diagnoses at the fuzzy boundary with normality.”

For example, the DSM-5 opens the door for patients worried about having a medical illness to be diagnosed with somatic symptom disorder.

Normal grief may be misdiagnosed as major depressive disorder, and the forgetfulness of old age may now be interpreted as mild neurocognitive disorder.

“The already overused diagnosis of attention-deficit disorder will be even easier to apply to adults thanks to criteria that have been loosened further,” Dr. Frances adds.

Other changes in the DSM-5 will allow clinicians to label a child with temper tantrums as having disruptive mood dysregulation disorder, and overeating can now be called binge eating disorder.

Real Danger

The real danger in diagnostic inflation is overdiagnosis and overtreatment of patients who are essentially well, he says.

“Drug companies take marketing advantage of the loose DSM definitions by promoting the misleading idea that everyday life problems are actually undiagnosed psychiatric illness caused by a chemical imbalance and requiring a solution in pill form,” Dr. Frances writes.

“New psychiatric diagnoses are now potentially more dangerous than new psychiatric drugs.”

Quite apart from the risk for overtreatment, however, is the risk of neglecting patients with clear psychiatric illness whose access to care has been sharply reduced by slashed state mental health budgets.

As Dr. Frances points out, only one third of persons with severe depression receive mental health care, and a large percentage of the swollen prison population in the United States is made up of true psychiatric patients who have no other place to go.

More damning, however, is the flawed process by which committee members of the DSM-5 arrived at their expanded diagnoses, in Dr. Frances’ view.

As he states, the DSM-5 did not address professional, public, and press charges that its changes lacked sufficient scientific support and defied clinical common sense.

Field trials produced reliability results that did not meet historical standards, and deadlines were consistently missed, he adds.

The American Psychiatric Association also refused a petition from an independent scientific review of the DSM-5 that was endorsed by more than 50 mental health associations.

Dr. Frances said he personally found the DSM-5 process “secretive, closed, and disorganized.”

“I believe that the American Psychiatric Association (APA)’s financial conflict of interest, generated by DSM publishing profits needed to fill its budget deficit, led to premature publication of an incompletely tested and poorly edited product,” Dr. Frances states.

“The problems associated with the DSM-5 prove that the APA should no longer hold a monopoly on psychiatric diagnosis…. The codes needed for reimbursement are available for free on the Internet.”

The APA declined to comment.

Ann Intern Med. Published online May 17, 2013. Full article

DSM-5: Past Imperfect. Medscape. May 18, 2013.

Retrieved from: http://www.medscape.com/viewarticle/804378DSM-5 Officially Launched, but Controversy Persists

By: Caroline Cassels

SAN FRANCISCO — After more than a decade of development and more than 2 years of frequently searing controversy, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has finally been released.

Here at the American Psychiatric Association’s (APA’s) 2013 Annual Meeting, the APA leadership officially launched the manual, which is widely known by clinicians and patients alike as the “Bible of Psychiatry.”

“This is really an important day. I have been involved with the DSM-5 almost from the beginning, and I have seen the work unfold over the past decade. There have been literally hundreds of people, experts from all over the world, from different disciplines, who have contributed [to the DSM-5],” outgoing APA president Dilip Jeste, MD, told reporters attending a press briefing here.

“What we are seeing is a clinical manual based on the best science available…for today’s patients, this is the best manual that we could develop,” Dr. Jeste added.

Key changes in the new edition include a new chapter organization that shows how mental disorders may relate to one another on the basis of underlying vulnerabilities or symptom characteristics.

In addition, in DSM-5, disorders are organized in the context of age — that is, along a developmental lifespan within each chapter — as well as sex and cultural expectations.

What’s New

According to DSM-5 Task Force chair David Kupfer, MD, although the number of disorders are “about the same” as in the last edition of DSM, several new disorders have been added, including binge eating disorder, disruptive mood dysregulation disorder, and hoarding disorder.

A new section for the manual, Section III, describes several conditions that warrant more research before they can be considered as formal disorders in the main part of the manual.

The changes to the manual are designed to help clinicians more precisely identify mental disorders and improve diagnosis while maintaining the continuity of care.

“We expect these changes to help clinicians better serve patients and to deepen our understanding of these disorders based on new research.”

However, not everyone is as enthusiastic about the manual’s release. Allen Frances, MD, who chaired the DSM-IV Task Force and is among the DSM-5’s staunchest critics, told Medscape Medical News that he is filled with “sadness and worry — and I am not a person usually given to either emotion.”

He added that he is very concerned that the “DSM 5 will result in the mislabeling of potentially millions of people who are basically normal. This would turn our current diagnostic inflation into hyperinflation and exacerbate the excessive use of medication in the ‘worried well.’ ”

“DSM-5 turns grief into Major Depressive Disorder; temper tantrums into Disruptive Mood Dysregulation; the expectable forgetting of old age into Mild Neurocognitive Disorder; worrying about illness into Somatic Symptom Disorder; gluttony into Binge Eating Disorder; and anyone who wants a stimulant for recreation or performance enhancement can claim Attention Deficit Disorder,” he said.

“Don’t Buy It, Don’t Use It”

However, incoming APA president Jeffrey Lieberman, MD, told reporters that the idea that the revisions to the manual will lead to overtreatment is “inaccurate and unwarranted.”

“The DSM is a diagnostic guide that reflects what we currently know about how best to define disorders. How it is applied is something that reflects clinical practice,” he said.

The manual’s diagnostic criteria, he added, are based on the current state of the scientific evidence to “verify the existence of a certain condition that we know to be impairing and distressing and enduring for people,” Dr. Lieberman added.

Dr. Frances also expressed concern that the new manual will divert scarce mental health care resources away from those who need it most.

“While we are overtreating people with everyday problems who don’t need it, we are shamefully neglecting the people with moderate to severe psychiatric problems who desperately do.”

His advice to frontline clinicians regarding the DSM-5? “Don’t buy it, don’t use it, don’t teach it. There is nothing at all official about DSM-5, and the codes for reimbursement are available for free on the Internet or in DSM-IV. APA is price-gouging a badly flawed document, no one need feel captive to it.”

NIMH Blog Not an Indictment of DSM-5?

Dr. Frances is not alone in his criticism of the manual. An April 29 blog post by Thomas Insel, MD, director of the National Institute of Mental Health (NIMH), and published on the NIMH Web site stated that although the upcoming manual is reliable, it lacks validity.

As reported by Medscape Medical News at that time, Dr. Insel pointed out that unlike diagnostic criteria for other diseases, the DSM-5 criteria are based on consensus rather than objective laboratory measures, and he noted that the NIMH will be “re-orienting its research away from DSM-5 categories.”

Toward that end, Dr. Insel went on to announce the launch of the NIMH Research Domain Criteria (RDoC) in a first step toward “precision medicine.”

Following Dr. Insel’s blog post, on May 14, the APA and the NIMH issued a joint statement in which the organizations emphasized the need to work together for the good of patients.

Nevertheless, the statement underscored the fact that the NIMH’s position on the DSM-5 had not changed and that “the diagnostic categories represented in the DSM-IV and the International Classification of Diseases-10 (ICD-10, containing virtually identical disorder codes) remain the contemporary consensus standard for how mental disorders are diagnosed and treated.”

However, Dr. Lieberman, who has since collaborated with Dr. Insel, said that the blog post should not be viewed as an indictment of the DSM-5 but rather as an expression of frustration that psychiatry does not yet have the biologically based diagnostic tools as other areas of medicine.

“Even though his blog was interpreted this way, we don’t think Tom intended to impugn the DSM so much as to say that he wanted to exhort the biomedical research community to try and break new ground that will lead to more dynamic and fundamental changes in psychiatric diagnosis,” said Dr. Lieberman.

The DSM-5 is available immediately in print, and an electronic version will be available later this year.

The American Psychiatric Association’s 2013 Annual Meeting. Opening press conference. May 18, 2013.

Retrieved from: http://www.medscape.com/viewarticle/804410

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