Sunday, October 13, 2013

UW Update - the Rest of the Story

I am back at my usual computer tonight and feeling much better after attending the UW Psychiatric Update. It was well attended and I estimate there were about 400 people there - mostly psychiatrists.  The conference brought in several people who were instrumental in the DSM-5 to talk about the thinking and research that went into it.  The resulting story is one that you will never hear in the press or other media.  The story is based on science as opposed to the irrational criticisms in the media and that science is written about and discussed by brilliant people.  I will try to post a few examples, and wish that it had been presented to the public.  The discussion produced for public consumption was not close to reality and it was a further example of how stigmatization of the profession prevents relevant information from reaching the public.  It seems that the most we can hope for is an actual expert being placed in a staged debate or responding to some off-the-wall criticism - hoping to interject a few valid points.  That is a recipe for selling the sensational and leaving out the scientific and rational.  Just how far off the media is on this story is a mark of how skewed that perspective is.

Let me start with the disclosures.  There were 14 presenters and 10 of them had no potential conflicts of interest to report.  That included one work group chair.  One of the presenters suggested that the political backlash against psychiatrists affiliated with the industry and the DSM limit on the amount of money that could be earned from the industry limited access to some experts and probably limits drug development.  His question to the audience was:  "What if it means that 10 years from, all we have to prescribe is generic paroxetine and generic citalopram?  What if we have no better drugs?"  It would be interesting to know who was specifically not able to participate in the process due to these restrictions.  There were primarily 2 presenters with extensive industry support primarily in their role as consultants to the industry.  One of them joked about his level of involvement: "Based on my disclosures you should probably not believe a thing that I say."  He went on to give an excellent presentation replete with references to peer reviewed research.

Before I go on to talk about specific speakers I want to address another frequent illusion about psychiatrists and that is that they are primarily medication focused and have minimal interest in other treatments.  That is convenient rhetoric if you are trying to build a case that psychiatrists are all dupes for the pharmaceutical industry and that drives most of their waking decisions.  During the presentation of the pharmacological treatment of obsessive compulsive disorder, the presenter clearly stated: "It could probably be said that we are still waiting for an effective medication for obsessive compulsive disorder."  Certainly, the section on autism spectrum disorder presented the current AACAP practice parameters and the fact that there is no medication that treats the core features but some that that have a "mild to modest" effect on some features or comorbidities.   Three of the four breakout sessions in the early afternoon of day 1 were psychotherapy focused.  I attended Mindfulness Based Cognitive Therapy and Recurrent Major Depression with about 200 other participants.  We were guided through two interventions that could be used in follow up individual sessions as well as groups.  The efficacy of preventing recurrent major depression with this modality alone was discussed.  The Psychotherapeutic Treatment of Insomnia and Pediatric Post Traumatic Stress Disorder were discussed in parallel sessions.  In the PTSD lecture, it was pointed out that there is no FDA approved medication for the treatment of this disorder and that the gold standard of treatment is Trauma Focused Cognitive Behavior Therapy (CBT).  That's right a psychiatric conference where the treatment of choice is psychotherapy and not medications.

What about he individual presentations on the thinking behind the DSM?  I was thoroughly impressed by Katharine A. Phillips, MD Chair of the DSM-5 Anxiety, Obsessive-Compulsive Spectrum, Post Traumatic Stress Disorder Work Group.  Reviewing the structure of the DSM-5 as opposed to the DSM-IV shows that all of these disorder previously considered anxiety disorders are now all broken out into their own categories.  She discussed the rationale for that change as well as the parameters that were considered in grouping disorders in chapters - clearly an advance over DSM-IV.  She talked about the two new disorders Hoarding and Excoriation (Skin Picking) Disorder and why they were OCD spectrum disorders.  She talked  about insight and how it varies in both OCD and Body Dysmorphic Disorder (BDD).   She discussed the new OCD Tic-Related Specifier and its importance.  Most importantly she discussed how the decisions of the Workgroup will improve patient care.  The most obvious example, is the case of BDD where both the delusional and non-delusional types respond to SSRIs and those are the drugs of choice and not antipsychotics.  By grouping BDD in with Obsessive Compulsive Disorder and Related Disorders recognition and appropriate treatment will probably be enhanced.  Dr. Phillips is the researcher who initially discovered the treatment response of BDD to SSRIs.  She is also a rare lecturer who does not pay much attention to the PowerPoint slides but speaks extemporaneously and authoritatively on the subject in a parallel manner.

Susan E. Swedo, MD was the Chair DSM-5 Neurodevelopmental Disorder Work Group.  She talked in detail about the elimination of the Pervasive Developmental Disorders diagnosis  and how the Autism Spectrum Disorder diagnosis reflected current terminology in the field over the past ten years and how it basically eliminated 5 DSM-IV diagnoses (Autistic Disorder, Asperger Disorder, Pervasive Developmental Disorder, Childhood Disintegrative Disorder, and Rett Disorder).  She pointed out that the Workgroup could only locate 24 cases of anyone who had ever been diagnosed with Childhood Disintegrative Disorder and that the CDC's epidemic of Autism was probably related to diagnostic confusion and overlap between PDD-NOS and Attention Deficit Hyperactivity Disorder. She gave a detailed response to the "publicized concerns about DSM-5" including decreased sensitivity to improve specificity, the loss of the uniqueness of the Asperger Diagnosis, and the fact that pre/post research in this area won't be comparable.  She showed a detailed graphic and comparison of DSM-IV and DSM-5 criteria to show why that is not accurate.

I came away from this conference refreshed and more confident than ever about the reason for writing this blog.  I had just seen some of the top scientists and minds in the field and why the DSM was really changed - not what you read in the New York Times.  If you are a psychiatrist - there were plenty of reasons for a DSM-5 and if you read this far, it is only the tip of the iceberg.

George Dawson, MD, DFAPA


  1. The reason that grief seamlessly blends into MDD is that MDD is now so broadly defined. All of those SSRI studies where half of the patients remit on placebo and 60% on the drug...what do you think is happening? The obvious answer is that many had self-limiting conditions in the first place. All those journal articles about comorbidity...what's that about? A lot of nebulous Venn diagram circles crashing into each other.

    Notice how the rebuttal relies on utilitarian arguments not scientific arguments. The idea of a disease being defined by dysfunction and reliability is specious. Draepetomia was reliable as a diagnosis and resulted in social dysfunction. If one goes back to the literature of Robins and Guze as well as the writings of Paul Meehl on nosology, there is no question that DSM is pseudoscientific and overly broad. DSM admits as much in the foreward. Read the last paragraph of page 31-32, DSM-4-TR. The book essentially indicts itself in being unscientific.

    Regarding MDD, what do you think is a more high quality data point? The presence of insomnia as determined in an interview with a primary doctor or an MMPI-2 valid profile with a 2 scale over 65 (encompassing dozens of questions in the context of test taking attitude)? And which data point is NOT considered relevant in DSM?

    1. As a person who has actually done clinical trials the increased placebo response is really no mystery. It is basically secondary to extensive comorbidity that allows clinicians and researchers to make alternate diagnoses. I can recall a trial I was doing where subjects tried to enroll in spearate trials based on the same set of mild symptomatology and I am very confident that has happened. The elimination of inpatients and patients with significant suicidal ideation is a second reason as well as inflated symptoms at baseline are additional reasons why the placebo response rate went form 20% in 1979 to 40% in 2000. The major psychiatric disorders are as valid today as they have been for the past several centuries. I think that the confusion about grief and depression stems from the fact that psychiatrists treat depression precipitated by grief but that is only a small percentage of people. The note and explanatory paragraph in DSM-5 attempts to capture what psychiatrists are taught about separating grief from depression. The issue occurs because it is clear that many psychosocial stressors including grief lead to a depression that would be treated by a psychiatrist.

      As far as your question about the MMPI criteria, I thought I might be missing something so I looked up in my complete set of Principles and Practice of Sleep Medicine sitting on my shelf. The first and fifth edition have nothing about the MMPI. The second edition talks about its use in bruxism. The third and fourth edition talk about its use in a survey of various instruments and significant limitations. I guess if I really did not known how to interview somebody about their insomnia I would choose one of the many more appropriate measures in Table 77-3 on page 841 of the fifth edition. The number of sleep disorder diagnoses I have made suggest that is unnecessary but it seems that the MMPI is not considered a high quality data point by the experts. But I suppose that could be dismissed by saying that like psychiatrists they are only interviewing people. I have seen many people "misdiagnosed" on a gross level by the MMPI, and some of those misdiagnoses are quite heinous. It is a curious application of 1950s technology to come up with algorithms that make modern diagnoses but I will probably have to defer to Meehl about that and whether it can possible come up with a psychiatric diagnosis with "actuarial" accuracy. I can't imagine why they would want to emulate pseudoscientific diagnoses.

      Drapetomania is a rhetorical comment that really doesn't merit a response. I will leave it up to the imagination of other readers to figure out why.

    2. I forgot - I don't have a copy of the DSM-4-TR so you will have to tell me how it indicts itself. I might have to get some of the more famous DSM-IV proponents to respond, since it appears they thought it was a superior document.

    3. To be Honest, i think Kupfer is much better than Allen. By the way, do you have any words for the chair on research?

  2. No words for the chair on research. I can't think of a better approach than was used to generate the latest DSM-5. I am waiting for Jon Grant's book to come out in the next month or two. Per my previous post Dr. Grant and his co-author Donald Black had exclusive access to all of the writings and e-mails of all of the work groups and I am hoping they have synthesized that information well. The naysayers to the process take that position that guy in your freshman philosophy class took - everything is relative and therefore there is no knowledge. Or as we have seen here it is quite easy to say that the convergent validity of major psychiatrist diagnoses is less relevant than the convergent validity of a number of true/false questions from the 1950's when trying to characterize problems in order to help people(!)

    Every psychiatrist I know has no problem figuring out what is grief and what is depression. The quote from Clayton's chapter in Paykel's text from the 1980's still applies whether there is a DSM or not. The psychiatry deniers take the basic approach that no matter what happens psychiatry and psychiatric diagnosis is irrelevant and unscientific or driven by conflict of interest. None of those ideas have validity.

    The APA is a politically imperfect organization. If that were not the case, we could develop an infrastructure to deliver up to date science to every psychiatrist and use that as a basis for ongoing certification rather than the arbitrary system that is currently being developed. I will post how that can happen this weekend.

  3. "I can't think of a better approach than was used to generate the latest DSM-5"

    Given the overall cost, delays, secrecy and final result, this is the best organized psychiatry can do?

    Who was it that said insanity is rare in people, common in groups? DSM may not be insane but it is a very boring, overreaching and intellectually vapid book that I believe no individual would have written.

    I don't think the major problem with DSM is big pharma. I think the major problem is groupthink. And it doesn't matter how smart or charming they are.

    Name the last book you read written by more than two people that was any good. Which is more readable, Stahl's book on psychopharm or Schatzerg's multiauthor textbook? What screenplay is better, Robert Towne's Chinatown, or Robert Towne as one of a committee of screenwriters on one of the Mission Impossible or some other garbage sequels? Does anyone claim Shakespeare should have coauthored Richard III with an expert in English history and an expert in horsemanship?

    With one author you get a singular vision and philosophical and stylistic coherence, with the other, you get something resembling a very bad piece of legislation, because it had to be watered down through the political process.

    Here's a better approach. Rather than having several hundred authors produce a book as a result of the political process, have the top ten psychiatrists in the field of nosology write the DSM, and have the other nine pick the best one.

    I have never been impressed by APA charm offenses. BTW, nice of them to be so forthright now when they were so secretive during the process.

    Also, claiming anecdotally that MMPI gave a false diagnosis is specious. We both have seen cases where board certified psychiatrists using DSM gave false diagnoses on a regular basis (which is not surprising when you look at the kappas). In forensic psychiatry, you almost never get experts on both sides to agree on the diagnosis.

    What about Ghaemi's article and his logic? I have read The Selling of DSM and it's not a pretty picture of the scientific method in action.

    Yes, I believe there are about 15-20 statistically constructionally valid diagnoses. That doesn't make me antipsychiatry or antipharma. It makes me anti-groupthink, the person in the Asch conformity study who dared to disagree.

    "Every psychiatrist I know has no problem figuring out what is grief and what is depression." Of course they do. But DSM tells you if you have five symptoms, the only difference is whether or not it is day 14 or day 15.

    1. I would prefer Schatzberg's text any day over Stahl's. In fact as I gaze up at my book shelf, the majority of my texts are multi authored (like the 5 volumes of Principles and Practice of Sleep Medicine - I just counted 184 authors to be exact). Technical works in a specialty field had better be multiauthored or a lot of information will not be covered.

      The problem with your groupthink hypothesis and the various DSM conspiracy theories is that there were just too many people involved to get caught up in that dynamic. I would think that a single source viewed as being definitive would be more likely to produce "groupthink" than a large collection of people who believe that they are experts and at the top of their game. By the way - what are the criteria for groupthink?

      You miss the point of my "specious" argument about the MMPI. Medical diagnoses are not supposed to be precise - hence my quote from Merskey about how medical diagnoses are no where as accurate as a phone book or a periodic table and that is ALL medical diagnoses. I have no doubt that an MMPI is useful for psychologists, but not in acute care settings or most places where I have worked for the obvious reasons. I think the false argument here is to suggest one method is better and use that as a valid argument. Forensic psychiatry and psychology for that matter has little to do with the DSM. The DSM is basically a tool for clinical psychiatrists to use as they see fit and they would all admit its limitations

  4. It's not a conspiracy theory (who did I say they conspired against?), it's human behavior. Conformity dynamics are well known by historians and psychological studies like Asch, Milgram, Stanford Prison and many other studies. But of course, you could go to a college football game and observe the obvious about human behavior in groups. Explain how having more people reduces groupthink. I would like to see the evidence of that.

    Forensic psychiatry and psychology have little to do with the DSM? I would love to know where you came up with that idea. I am board certified in forensic psychiatry and that is most certainly NOT true. It's used all the time and quite a bit of effort in deposition goes into questioning and defending diagnosis.

    Multiauthored texts in my opinion are tedious and nearly impossible to get through. They may be useful as references but are not good reads. There is a lack of a coherent style and narrative that bore the reader. Schatzberg's text is a jumble of noncommittal hedged statements, Stahl tries to make dry material as engaging as it can be and at least makes a commitment toward various approaches. I don't care how esteemed experts are in their fields, most can't write well. I'd rather read a book by one author who knows the material and can. And I'm sure if Meehl or Ghaemi or Guze wrote the DSM, it would be much better than the PR disaster and gift to Scientology that is DSM 5.

    I gave you Ghaemi's arguments against DSM. You can't rebut them by just insisting it's science anyway and the DSM people are good guys. And you certainly can't by using the straw man of "conspiracy theory" as a broad brush.

    1. So I guess there are no criteria for groupthink? It could be anything from a mob at a football game to a bunch of eggheads debating diagnostic criteria. I heard a terrorism expert apply it to the dynamics within terror cells. I guess loosely applied it could be any product or behavior of a group that we are in disagreement with. Unless you can come up with a better definition, it will be impossible for me to explain how several hundred people with their own clearly delineated interests and rarely under the same roof would be less susceptible.

      With regard to your comment on forensics and the "lack of agreement" by experts. My experience in that the experts will agree with the side that is paying them. They will naturally argue for that diagnosis. What does that have to do with appropriate use of a diagnostic manual? I recommend reading the "Cautionary Statement for Forensic Use of DSM-5" on page 25 including par 3, line 2 and 3: "When DSM-5 categories, criteria, and textual descriptions are employed for forensic purposes, there is a risk that the diagnostic information will be misused or misunderstood.....". And yes I am pulling that out to illustrate my point so I don't have to type the whole page here. You and I both know that when psychiatrists are in court there are many other things in play in addition to what a diagnosis may or may not be.

      Conspiracy theories about the DSM abound. Are you telling me that you are unaware of them? Go back and read the pages on this blog and I have outlined them.

      As far as Ghaemi's article goes - you will have to send me a copy. I do have several of his books and I will end will a statement from "The Concepts of Psychiatry" after talking about how psychiatry is scientifically based using Weber's definition:

      "Thus although ideal types are limited, can be misinterpreted, and do not have the general reproducibility and ease of validation of the empirical method, they are useful nonetheless and can go hand in hand with empirical research in helping understand and treat individuals with psychiatric conditions.

      The DSM nosology is best understood in this context, in my opinion, and in improving patients' lives and in promoting diagnostic and treatment research, albeit with many limitations." p. 184

      That is Ghaemi's argument for the DSM. I am using Ghaemi against Ghaemi but send me his article and I will read it. Like anyone else he can change his mind. One of the most compelling points in my original post above is Dr. Phillips discovery that Body Dysmorphic Disorder responds to SSRIs and not antipsychotics. Making that correction ALONE is worth a new manual to me, but I suppose it depends on how much severe tardive dyskinesia you have had to treat over the course of your career.

      As far as the ongoing argument goes, at this point it should be apparent as it always is on the internet that there will be no winner. Why waste your time here? I would encourage you to go forth to any number of psychiatric blogs where the raison de'etre is to bash psychiatry for one reason or another. It should be easy to do - they abound!

      I hope it is apparent by now that this is not one of those places and for very good reasons.

    2. I will repeat this again so it is clear. Criticizing DSM is not the same as bashing psychiatry. I believe there are mental illness. I do not believe there are 300-400 separate and distinct mental illnesses. Relativism can take two forms...saying mental illness doesn't exist labeling everything bad that happens a mental illness. There are two possibilities here...that a forensic psychiatrist who treats patients and uses psychiatric medication is antipsychiatry or that a fundamentalist supporter of DSM and the psychiatric establishment has difficulty handling criticism that was never meant to be personal. So I suggest you check your anger. This is not personal.

      I linked to Ghaemi in an earlier post. His article is in Psychiatric Times under DSM discussion. It is quite elegant and not antipsychiatry.

      DSM-5 was scientifically dead on arrival. We do not treat diseases or mental disorders anyway. We treat symptom endophenotypes. This is the future of psychiatry. Baby boom psychiatrists will hang on to DSM while younger psychiatrists who understand genetics will move on.

      I regret that you took my rather moderate position as antipsychiatry, but I have made it abundantly clear that this is not my position.

      You seem like a bright man but kind of a joiner who can't break from the APA wolfpack when it is heading off a cliff. You accuse your intellectual opponents of conspiracy theories but yet you buy into the idea that all DSM criticism is antipsychiatry, or worse, a personal attack. I assure you this was not my intent.

      I don't know what it is about psychiatry that supposedly evolved professional cannot discuss opposing ideas without someone's ego getting bruised or taking personal offense. This is really part of the sensitivity groupthink problem that pervades psychiatry and psychology. Soft headed does not mean soft hearted. The goal with patients is to be empathic, but when discussing the science of psychiatry we should not be afraid to criticize nonsense when we see it.

      This article is incredibly germane to this debate and should be read by anyone in mental health:

    3. I looked up the meaning of DFAPA. Now I understand where you are coming from. Institutional loyalty is a powerful thing. You won't hear from me again.

  5. Thank you for your consideration. Your idea that my positions are part of "institutional loyalty" are off the mark. A casual look at the posts here that criticize the APA for being ineffective, supportive of managed care and the PPACA, and ineffective advocates for people with serious mental illness, addictions, and problems with violence and aggression are obvious cases in point. I am also highly critical of them for their role in MOC efforts and yielding to the ABMS in that area. You will never see a person with my opinions as an APA insider. Curiously the same standard that you are using is never applied to people who make a good living criticizing psychiatry.

  6. Who is angry? Anyone who disagrees with you. I have addressed your arguments without ad hominem or condescension. I am referring to a well known phenomenon that has been documented about disproportionate criticism of psychiatry everywhere in the media. The cultural phenomena is that it parallels disproportionate rationing of psychiatric services to the point that they have been closed down and transferred to correctional facilities. My contention is that there is a connection there. It is much easier for insurance companies and governments to ignore the plight of people with severe mental illnesses. That dynamic is clearly the biggest threat to psychiatric services in this country. The DSM approach isn't even visible in the rear view mirror in terms of a threat. And yet - I am the only guy pointing that out. The last president of the APA who pointed that out with any consistency was Harold Eist in the 1990s.

    We (and many medical specialists) treat syndrome endophenotypes. See my post on asthma endophenotypes for comparison. Many diseases that we all learned in medical school are heterogeneous and interestingly the endophenotype approach was applied initially in psychiatry by Gottsman and is spreading to other areas although many are using the term intermediate phenotype instead. Interestingly there is no rancor among specialists who treat asthma about the appropriate number of diagnoses or that the scientific debate about diagnostic criteria means that their new approach is "dead on arrival" (I have a post on this blog about that very topic).

    You are incorrect about the total number of DSM diagnoses. One of the main critics of the DSM-5 a previous Task Force Chair criticized the issue of diagnostic proliferation and the current number of DSM-5 diagnoses is 157. One of the major advances of DSM-5 was pruning diagnoses and making diagnoses less ambiguous. It appears that the total number of diagnoses maxed out during his tenure:

    I guess I am doomed to continue my soft headed ways until I can be rhetorically convinced otherwise. It would have to be rhetoric because there is an apparent paucity of facts.

    I will end with a response to the criticism of "baby boom" psychiatrists desperately clinging to our lack of science knowledge until the younger generation of geneticists can take over. Many of us knew a lot of science (and genetics) before we knew psychiatry and have been waiting for the field to catch up. I will let you know when that happens.