Just when you think that Allen Frances has run out of
editorial venues for his anti DSM5 critiques another one pops up. This time it is in the Annals of Internal Medicine.
This is a note about that process before I get into addressing his
repetitive critiques. The Annals is a respected medical
journal. For a number of years I was an
ACP member and subscribed to it myself.
Why would the Annals go along
with publishing an editorial piece that is basically a rehash of what has been
published in the New York Times and
the Huffington blog and who knows
where else? There is really precious
little science involved. I think the
only logical explanation is that the staff of the Annals has jumped on the popular bias against psychiatry that has
been widely noted in the press by Claire Bithell and her group that studies these
issues. I am not a current subscriber
to the Annals but the question is whether
there was equal time for rebuttal. If not is this professional bias against psychiatry?
Probably the best way to address this rehash of old
criticisms is to link up to previous blog posts here where that occurs. Beginning in paragraph one Dr. Frances cites
a famous study about pseudopatients
as though it has some applicability to the issue of “unreliable and inaccurate”
psychiatric diagnosis. He cites this
study as if it is somehow relevant to the problem. All of the considerable scholarship refuting
this study as meaningful by various authors including Spitzer and Kety is
ignored. Using this as a premise for a scholarly
article on the validity of psychiatric diagnosis should raise an eyebrow or
two, but on the other hand I doubt that there is anyone on the editorial board
at this Internal Medicine journal who is familiar with this literature.
The issue of diagnostic inflation is a frequent critique
used by Frances and others to suggest that this invalidates the DSM5. Most people are very surprised to learn that compared
to previous editions and the ICD-10 this is really
not an issue. The previous blog post
illustrates that compared to the ICD-10, the possible increase in diagnostic
categories in the DSM is trivial. The increase in the number of codes for a
knee fracture alone approximates the total codes in the DSM! Contrary to his description of “holding the
line” with DSM-IV diagnoses – the data presented in that post shows that the
DSM-IV added twice as many diagnoses as the DSM5 will.
Dr. Frances uses the “no bright line” approach to say that
there is no way to separate the worried well from people with disorders. There certainly is no written “bright line” in
the DSM. Every DSM has a section with
qualifying statements about its use and that fact that diagnostic criteria
alone are not sufficient. A psychiatric
diagnosis, especially a diagnosis made by psychiatrists in the same group with
the same focus is very consistent and it is a reliable marker of illness
severity. Professional judgment is required. The “no bright line” issue is
not a problem that is unique to psychiatry.
It is omnipresent in general medicine with regard to chronic pain
diagnoses, chronic pain treatment, and in the overprescription of pain
medications and antibiotics. The overprescription of antibiotics has been
identified as a problem by the Centers for Disease Control (CDC) for 20 years
and recent authors suggest that minimal progress has been made. It seems that other specialties are subject to
the “fallible subjective judgments” suggested in this article.
Another implicit myth used by Dr. Frances and other critics
of psychiatry is that there is some magical diagnostic process that occurs in
medicine and surgery that makes them better than psychiatric
diagnoses. What happens when we test
that theory by looking at the reliability of general medical diagnoses? Looking at that data, it is clear that the
published reliability data from medicine and surgery is no better than the frequently criticized data from psychiatry even when objective medical tests are used. Practically everyone I know has a favorite
story about a misdiagnosis and/or ineffective treatment of a medical or
surgical problem. That evidence does not
support the contention that psychiatry is somehow less accurate or effective
than the rest of medicine. Some medical
specialties used similar descriptive techniques even when they have numerous
biological markers of the illness. The
other elephant in the room on this diagnosis issue is medically unexplained
symptoms. The studies of all patients
coming in to a clinic setting suggest that 30% do not get a diagnosis to explain their
symptoms. These patients often get multiple
tests looking for a cause for their problem.
This is by far the most significant problem that I hear from relatives, acquaintances,
and the public in general. If nonpsychiatric
medical diagnoses are supposed to be highly accurate based on biological tests –
a substantial number of people never actually experience that.
On the fuzzy diagnosis in psychiatry critique, a common
theme here is to go after the bereavement exclusion and suggest that normal
bereavement will be treated like depression.
I have an extensive
response to this when it was posted in a newspaper article and invite any
interested reader to look at the previous blog post and the fact that this
approach to grieving patients who come to the attention of psychiatrists has
been written about for over 30 years (see last 5 paragraphs at link). Practically every point in this section of
the editorial can be disputed but the point of the article is not a scientific
review, it is basically a selection of comments to support a specific
viewpoint.
To Dr. Frances credit he references an excellent
meta-analysis by Leucht,
et al on how the results of psychiatric treatment are as good or better
than the results of other medical specialties.
He is silent on how that occurs if psychiatric diagnosis is so unreliable
and inaccurate. How is it possible to
get results that good compared with
other specialties? Maybe it is because
as I have just suggested, the “special problems” in psychiatric diagnosis are
really general problems that are shared by all medical specialists?
The criticism is less focused in the final paragraphs with
some commentary on style points about the DSM political process, the issue of conflict
of interest focused on publishing profits, and the idea that the APA should
submit the DSM to oversight by a broad coalition of “50 mental health
associations”. Let me take the last
point first. There are a number of other
diagnostic approaches and manuals that have
been completed by coalitions of several other mental health organizations. With the number of different approaches, I
would encourage any organization to publish their own approach to the diagnosis
of mental disorders. Contrary to the
rhetoric suggesting that there is a DSM monopoly, nothing could be further from
the truth. The entire text of the World
Health Organization’s (WHO) ICD-10 is available free online. The Mental and Behavioral Disorders section
of the ICD-10 gives detailed descriptions of each disorder. The detailed
research criteria for ICD-10 can be purchased for about ¼ the cost of a DSM5. It seems to me that there is a marketplace of
ideas and plenty of competition. If I
was not a psychiatrist with an interest in reading about developments in my
field, I would not be compelled to purchase a DSM5. I would probably take a few courses in the
changes to DSM-IV and stick with that for a while.
On the issue of submitting the DSM5 to outside groups there
are several compelling reasons why that would not be a good idea for most
psychiatrists. Some critiques
have suggested that psychiatry should be open to forced collaboration by others
based on previous relationships. Over the span of
my career, I have noted that there is often an adversarial
approach by other organizations rather than an affiliative one. And why wouldn’t there be? This is the United States and everyone here
is familiar with the competitive and politicized atmosphere. It seems like that has been left out of the equation
when charges of “conflict of interest” are leveled at the APA in the area of
publishing a DSM. A recent critique of
the DSM5 also suggested broader collaboration with social scientists and I
critique that article here. The political slant of all of these articles
is that the APA needs the input of others to improve descriptive psychiatry. Including that in an article that has a basic
thesis that: “We will be stuck with descriptive psychiatry for the forseeable
future.” (line 27-28) being a negative is inconsistent.
If anything Dr. Frances seems to be suggesting that we should be moving
more to the biomedical side and distancing ourselves from the social scientists. The bottom
line here is that the DSM5 is a diagnostic guideline for psychiatrists to use
in clinical practice. It is not
synonymous with a psychiatric diagnosis and it is used at some level by
psychiatrists to understand mental disorders.
It is not designed for anyone to read and act like a psychiatrist and it
has nothing to do with people who do not have psychiatric problems. It is not a “Bible” like the New York Times
suggests. It is a tool for psychiatrists
and if you are not a psychiatrist there may be no reason for you to buy it or even
think that it is relevant to you.
On the issue of Dr. Frances serial DSM5 critiques - this
seems like a war of attrition to me. Dr. Frances has an infinite number of venues that are quite willing
to publish his very finite and repetitive criticisms of the DSM5 and the
associated process. Outside of myself –
there appears to be nobody else including the American Psychiatric Association who is willing to offer the
obvious counterpoints. He has more time
on his hands and many more connections than I do. So in terms of sheer volume I guess this is a
Pyrrhic victory of sorts. I will have to
be content with expressing the opinion of a psychiatrist who practices real
psychiatry, making diagnoses and helping people every day and knowing that my
results are on par with anybody else in medicine and that there is nothing random about
it.
George Dawson, MD, DFAPA
