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