Showing posts with label DSM 5 implementation. Show all posts
Showing posts with label DSM 5 implementation. Show all posts

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

Saturday, October 12, 2013

DSM 5 Total Diagnoses Revealed

As any reader of this blog can recall one of my foci is to expose the anti DSM 5 rhetoric for what is was.  One the the main points by DSM detractors was diagnostic proliferation or more total diagnoses.  This implies more diagnoses, more prescriptions, and more money for psychiatrists and pharmaceutical companies.  Another spin was that it was the intent of organized psychiatry to "pathologize" the population.  I put up a table on this issue in a previous post and at that time did not have the final number of diagnoses.  As of today I have the final number and it is 157.  According to the presenter that means that a total of 15 diagnoses were eliminated from DSM-IV to DSM 5.  The total diagnoses in DSM 5 did not increase as the detractors predicted - they decreased by 15.

I was at a conference today put on by the University of Wisconsin Department of Psychiatry entitled Annual Update and Advances In Psychiatry.  The Introduction by Art Walaszek, MD acknowledged that this was the first in a series that replaces a long tradition of courses run by John H. Greist, MD and James W. Jefferson, MD: "Jeff Jefferson and John Greist ran this conference for 31 years."  That is an amazing track record and record of achievement and a contribution to psychiatry in the Midwest.  I don't know of many psychiatrists who were not aware of this conference with the alliterative titles like:  "Quaffing Quanta of Quality from Quick Witted Quinessentialists" or the Door County Course they regularly taught.  They have been a model of scholarship and professionalism and continue to be.

The first speaker today was Alan Schatzberg, MD.  He posted the information about the total diagnostic categories in DSM 5 an other important changes and how they occurred.  Per my previous post about the DSM 5 lectures by Jon Grant, MD the DSM 5 effort was outlined in addition to some critical information on how stigma affects psychiatric diagnosis.  For example, when the DSM 5 work group wanted to add mild neurocognitive disorder a well known historian of psychiatry came out and said it would add countless people who had normal memory impairment associated with aging.  When neurologists added mild cognitive disorder to their diagnostic nomenclature (an equivalent diagnosis) no such claims were made about neurologists.  In terms of the effort, Dr. Schatzberg pointed out that there were 13 conferences from 2003-2008 that produced 10 monographs and over 200 journal articles.

Dr. Schatzberg and his colleagues presented a ton of information today on what really happened with DSM 5 development.  I will try to summarize and post additional comments when I can post from a more user friendly computer.  I wanted to keep the post more on the scientific and debunk another common refrain from the naysayers before the DSM 5 was printed.  That involved the so called "bereavement exclusion" that basically says that a person cannot be diagnosed with major depression if they are seen during an episode of grief.  One question that was never brought up in the popular press "Where did this convention came into the diagnostic criteria in the first place?"  I quoted a text from about the same time (see third from last paragraph) that makes this convention seem even more arbitrary.  It turns out the original bereavement exclusion began in DSM-III not from any research basis but from convention that was subjectively determined by the authors of DSM-III.  Contrast that with the research done by Zisook,  et al. You would think that some of the self proclaimed level headed skeptics out there would have referred to this critical paper on the issue rather than speculative attacks on the field.  Incorporating these scientific findings was one of the reasons that the DSM was updated.

Stay tuned for more of the hard data and insider info on DSM 5.

George Dawson, MD, DFAPA

1: Zisook S, Corruble E, Duan N, Iglewicz A, Karam EG, Lanouette N, Lebowitz B, Pies R, Reynolds C, Seay K, Katherine Shear M, Simon N, Young IT. The bereavement exclusion and DSM-5. Depress Anxiety. 2012 May;29(5):425-43. doi: 10.1002/da.21927. Epub 2012 Apr 11. Review. Erratum in: Depress Anxiety. 2012 Jul;29(7):665. PubMed PMID: 22495967.

Supplementary 1:  The DSM-5 Guidebook by Donald W. Black, MD and Jon E. Grant, MD came out in March 2014.  Table 1.  (p.  xxiii) lists the total diagnoses is DSM-5 as 157 excluding "other specified and unspecified disorders".