The First 25 Pages….

 

I was minding my own business on Twitter last week and noticed a slide posted with the image of the DSM-5.  It did not take too long the realize that it was not posted by anyone who had read the DSM – at least not the first 25 pages.  These pages are technically the introduction to the diagnostic section of the manual.  Important words because they summarize the process, orient the reader to the manual, and describe several important qualifiers.  That is how I was able to tell that the slide on Twitter had nothing to do with the DSM.  The statements made about it were essentially false.

The first problem is the characterization that diagnoses are “operational criteria” and that therefore it is a “fallible tool”. These are common mistakes by anyone who has not been trained in medicine and the understanding of disease states.  For simplicity, consider the definition from my physical diagnosis text from medical school:

"For several thousand years physicians have recorded observations and studies about their patients.  In the accumulating facts they have recognized patterns of disordered bodily functions and structures as well as forms of mental aberration.  When such categories were sufficiently distinctive, they were termed diseases and given specific names. “ 

 

DeGowan and DeGowan, Bedside Diagnostic Examination. 1976, p 1

 

The introduction notes that the precursor to the American Psychiatric Association (APA) published the precursor to the DSM back in 1844.  Even before that, the description of psychiatric disorders stretches back for thousands of years. The above definition notes the importance of patterns that are consistent over time.  A detailed description of these patterns and those evolved descriptions is how all of medicine has advanced.  The other important aspect of these descriptions is that they are sufficiently descriptive.  In the most basic analysis, the DSM is the standard way that physicians have indexed diseases and medical problems from the beginning.  The idea that it is merely “operational criteria” as in arbitrary routine measurement is far from accurate. The introduction is very clear that a diagnosis is not a checklist of symptoms and that a formulation is required.

The fact that the DSM inconveniently contains a Neurocognitive Disorders chapter and qualifiers about ruling out all other medical illnesses as causes of the presenting disorder is typically not mentioned by the discrete pathological lesion crowd.  If it is, the standard rhetoric that is applied goes something like this: "Well it is a disease it's just no longer a psychiatric disease. When real diseases are discovered they are no longer in the purview of psychiatry."  Even though psychiatrists have been diagnosing and studying these diseases for over a hundred years.

 One of the frequent mischaracterizations of medicine and psychiatry is that it operates from a biomedical model. This is confusing to a lot of people because physicians are certainly trained and interested in the molecular biology of both normal human function and all of the associated pathophysiological functions. Psychiatrists are interested in brain function in particular but also other systems that directly affect psychiatric care. Every psychiatrist has performed physical and neurological examinations at some point in their career.  Every psychiatrist has done a detailed neurological examination. Every psychiatrist has seen and read ECGs and brain imaging studies. That does not mean that psychiatrists don’t know the limitations of standard medicine when it comes to analyzing problems generated by both the brain and its associated conscious state.  If fact, psychiatrists have some of the best analyses and criticisms of these approaches. The standard biomedical model criticism is used to suggest an absurd degree of reductionism.  That is a model that no psychiatrist adheres to and the evidence is the statement in the DSM about multiple underlying causes of mental disorders.  Interestingly many of these same critiques often advocate for specific psychosocial causes of mental disorders on a global scale – a form of psychosocial reductionism.

 

There are often philosophical digressions on the nature of mental illness and whether mental illness is a disease or not.  I have written fairly extensively about that in other areas of this blog.  For the purpose of addressing the slides I will say that the lesion basis for both mental illnesses and physical illnesses was addressed from within the field in response to the pathological theories by Virchow and Koch. Interestingly, the answer to that theory was a study of hypertension:

“It was in fact the example of hypertension which finally discredited the nineteenth-century assumption that there was always a qualitative distinction between sickness and health. The demonstration by Pickering and his colleagues twenty years ago (5) that such a major cause of death and disability as this was a graded characteristic, dependent, like height and intelligence, on polygenic inheritance and shading insensibly into normality, was greeted with shock and disbelief by most of their contemporaries, and the prolonged resistance to their findings showed how deeply rooted the assumptions of Koch and Virchow had become.” (2)

Sixty years later, some academics apparently still have a hard time realizing that mental illnesses are polygenic illnesses of varying severity and a source of significant death and disability and yet there is no clear qualitative difference between illness and disease demarcated by a lesion.  We are well past the time that they should be ignored.

 Conflict of interest is also a favorite tactic of those who seek to discredit psychiatry.  The suggestion in the original slide was that both committee approaches and pharmaceutical influence were sources of corruption.  The first 25 pages describes why this is not true.  The financial limitations of committee members were significant. In the intervening 6 years since the DSM-5 was released there has been no evidence of pharmaceutical influence.  Why would there be?  Pharmaceutical companies can come up with any indication they need for medication indications. They don’t need a manual to develop a symptom list and initiate a clinical trial for that purpose.  Anyone who has actually read the manual notices that the highlights under each category stress a pluralistic approach to mental illness and no actual treatment approaches are described.  The vast majority of new pharmaceuticals are prescribed by non-psychiatrists like primary care physicians and physician extenders. In my experience, many of these prescriptions are for transient conditions that a psychiatrist would not prescribe a medication for.

 

The current reality is this.  The DSM consider mental disorders to be disorders. They don’t address the issue of what is a disease and what is not. The manual is very clear about their process and the fact that it is a work in progress. That is nothing unique to psychiatry. Diagnoses are always in a state of flux across all of medicine and that even includes diagnoses that are defined by particular lesions.  As the science of medicine advances, expect more diagnoses and large diagnostic categories like asthma, diabetes mellitus Type II, and depression to be broken up into smaller and smaller categories that will probably correlate with physiological findings.  The authors of DSM-5 are very clear that the manual is designed to be a cooperative document with both NIMH Research Domain Criteria (RDoC) for research purposes and International Classification of Diseases 11th revision (ICD-11) for administrative an epidemiological purposes.  The good news is that if you are not a psychiatrist or mental health clinician the details contained in the manual are probably not useful for you to know.  On my blog, I pointed out that even primary care physicians don’t read it, so why would anyone else?

 Psychiatrists have obvious theoretical and historical interest in the manual, but on a day to day basis it is safe to say that nobody is closely reading it except for researchers. It is very apparent that the so-called critics of psychiatry rarely do or they would not be adhering to premises that are clearly wrong at the outset. Equally disappointing is the endless stream of philosophical arguments that make similar errors. I read a paper by Jefferson (6) less than a month ago where she posits three different ways that mental disorders can be considered brain diseases. And of course the first one is Szasz’s – specifically:

 

“If Szasz is right, the very idea that mental illness is an illness depends on the idea that there is independent brain pathology causing mental distress.”

 

She goes on to say that Szasz ”drew a skeptical conclusion” from his own definition of brain disease and concluded that most mental disorders were not brain diseases. I seem to be the only one that recognizes that Szasz has been wrong about a lot of things for a long time, most notably the restricted pathologically based view of any or all diseases. 

 

That doesn’t seem to prevent it from being dragged out time and time again. The realm of philosophers and antipsychiatrists is apparently the only place Szasz is never wrong. And people can say whatever they want about the DSM-5 – even if they clearly have not read the first 25 pages.

 

 

 

 

George Dawson, MD, DFAPA

 

 

 

References:

 

1:  Leonard A. The theories of Thomas Sydenham (1624-1689). J R Coll Physicians Lond. 1990 Apr;24(2):141-3. PMID: 2191117; PMCID: PMC5387565.

 

2:  Kendell RE. The concept of disease and its implications for psychiatry. Br J Psychiatry. 1975 Oct;127:305-15. doi: 10.1192/bjp.127.4.305. PMID: 1182384.

 

3:  Smith R. In search of "non-disease". BMJ. 2002 Apr 13;324(7342):883-5. doi: 10.1136/bmj.324.7342.883. PMID: 11950739; PMCID: PMC1122831.

4:  Meador CK. The art and science of nondisease. N Engl J Med. 1965 Jan 14;272:92-5. doi: 10.1056/NEJM196501142720208. PMID: 14223129.

5:  Oldham PD, Pickering G, Fraser Roberts JA, Sowry GS. The nature of essential hypertension. Lancet. 1960 May 21;1(7134):1085-93. doi: 10.1016/s0140-6736(60)90982-x. PMID: 14428616.

6:  Jefferson, A. (2021). On Mental Illness and Broken Brains. Think, 20(58), 103-112. doi:10.1017/S1477175621000099

Graphics Credit:

Slides are all made by me with appropriate referencing.  Click on any slide to enlarge.

 

 

 

Racing Thoughts?

From the DSM-5 under criteria B.4. for a manic episode: "Flight of ideas or subjective experience that thoughts are racing." (p.124). In a previous post I discussed how easy it was to make a reliable diagnosis of bipolar disorder because the patient needs to describe a clear cut episode of mania. The main problem becomes determining whether they are actually describing a manic episode or not. There are a significant number of confounding factors in that determination. The best way to illustrate what I am talking about is to focus on how the term racing thoughts is used in psychiatric evaluations by patients rather than psychiatrists. DSM technology gives surprisingly little guidance on what a racing thought is. In clinical practice that is very problematic, especially if psychiatrists are depending on the observations of untrained observers. People who appear to be hyperactive or agitated and hypertalkative are frequently described as having racing thoughts. In many cases when asked directly they will reply: "My thoughts are always fast." or "This is normal for me." or "What do you mean by racing thoughts?  I don't know what that means."  At the observer level, many observers have reported to me: "The patient states he is having racing thoughts" as though that is diagnostic.  It may be - but it also might not be.

One of the commonest scenarios for racing thoughts doesn't involve mania at all.  It involves anxiety and insomnia.  Initial insomnia is a case in point as in: "I try to fall asleep but as soon as my head hits the pillow my thoughts are racing and I am thinking about a million things. After a while I look at the clock and it is 2AM." In the sleep literature the experience of racing thoughts here is associated with the phenomenon of hyperarousal and it is the commonest form of initial insomnia.  In other words, when I go to bed to sleep at night - I have really trained myself to think about all of my problems for several hours before I fall asleep.  It is not about sleep at all. Subjectively a person may thinking about every hypothetical in order to prevent mistakes - a common cognitive error of the anxious.  Many people experience this high arousal and excessive worry state as racing thoughts, but the main difference is probably in the time domain. The insomniac experiences a compression of time.  The worry is continuous and at least initially there is some surprise that hours have passed and there is no onset of sleep.  When the insomniac wakes up in the morning the racing thoughts are probably not there. With an episode of mania the racing thoughts are usually phasic change until the manic episode resolves or a different cognitive process occurs like increasing incoherence and distractability.

One of the best modern sources of information on psychiatric phenomenology remains Andrew Sims' Symptoms in the Mind. His discussion of racing thoughts is more comprehensive than most and far superior to anything that you will find in the DSM.  I am sure that the DSM authors will point out that this is why psychiatric training is necessary to use the book and that the book is not a substitute for training in phenomenology. Without that training racing thoughts on the part of the patient or the observer is often anyone's best guess. The best example I can think of was a patient who was being presented to me as "histrionic and overly dramatic" who was in fact manic. It is difficult if not impossible to sustain a dramatic presentation of mania, racing thoughts and pressured speech for any length of time.

The Sims discussion of racing thoughts occurs in his chapter: Disorder of the Thinking Process. In it he uses what he refers to as Jaspers model of thought association.  As illustrated in the tables, people tend to proceed from one constellation of thought to another unless they have specific disorders of thinking.  Sims diagrams out the thought disorders using a very nice graphic to illustrate these clusters and how a person moves from one cluster to another.  I have included a couple of examples in the tables here and how the thoughts proceed as indicated by the red arrow.  As I thought about it there are some differences with anxiety and mania.  The anxious person will be operating form clusters of questions and doubt.  That leads to more and more branch points or worry.  The manic person on the other hand especially if they have grandiose and expansive mania is not operating from excessive worry or doubt but declarative statements consistent with their confidence level.  As I thought about both people trying to sleep, the anxious person would be laying in bed the entire time, probably with their eyes closed going through these constellations of thought.  One of the commonest sleep complaints they describe is: "I can't shut my mind off - it is racing."  

The manic person for the same time frame would undoubtedly be up and engaged in some activity late into the night - if not for the entire night while experiencing a rapid progression of thoughts.  They will often describe their thoughts as going too fast to describe and certainly too fast to speak, even though many can speak at a very fast rate.  A secondary phenomenon that I typically ask about is excessive thoughts with no progression or what Sims calls "crowding of thought."  His specific description is that thoughts are being passively concentrated and compressed in the head: "the associations are experienced as being excessive in amount, too fast, inexplicable and outside of the person's control."  Sims sees this as occurring in schizophrenia, but I have definitely asked that question to manic patients and had them agree that was happening to them.  Jaspers also describes flight of ideas as a massive flow of content without an increase in the speed of thinking. 

The interesting aspect of focusing in only on the conscious experience of racing thoughts is that there is not necessarily an associated pressured speech.  Andreasen defined 18 different thought disorders in her early work and one of them was pressured speech.  She defined pressured speech as a rate of at least 150 words per minute. (3).

From a clinical standpoint a number of syndromes present with self descriptions of racing thoughts including anxious and agitated depressions, some forms of attention deficit~hyperactivity disorder, various intoxication states.  Racing thoughts is often the first phenomenon described by people who are under a lot acute stress and in some cases physical illness.  Many people become delirious for one reason or another and describe what amounts to a state very similar to pre-sleep reverie as racing thoughts.  The recent literature on racing thoughts supports the observations in this post and suggests that thought overactivation that includes both racing thoughts and overcrowding is a common phenomenon in mood disorders including unipolar states.  It also highlights an inherent limitation of the DSM - despite an abundance of descriptors it is inherently weak on phenomenology and this needs a lot of work with trainees who may be too focused on the DSM as a system for indexing rather than a comprehensive diagnostic system.  The criteria of racing thoughts certainly seems to lack specificity at several levels and clinicians encounter a broad spectrum of people who describe racing thoughts and do not have mania.  

Rather than a central feature of the diagnostic process, I would speculate that most experienced clinicians find that racing thoughts are an elaboration down the mental checklist after they have a detailed history of mood, activity level, and sleep changes.  At that level most of these clinicians are matching patterns of hundreds or thousands of people treated rather than specific written criteria.


George Dawson, MD, DFAPA



References:

1:  Andrew Sims. Symptoms in the Mind. Third Edition.   Elsevier Limited, Philadelphia, USA, 2003: p. 149-155.

2:  Karl Jaspers. General Psychopathology. Volume I.  John Hopkins University Press.  Baltimore, Maryland, 1997. p. 210-213.

3:  Andreasen NC. Thought, language, and communication disorders. I. Clinical assessment, definition of terms, and evaluation of their reliability. Arch Gen Psychiatry. 1979 Nov;36(12):1315-21. PubMed PMID: 496551.

Dr.Ghaemi on Dr. Spitzer

Nassir Ghaemi, MD has a commentary on Robert Spitzer, MD in this month's Clinical Psychiatry News.  After citing quotes by Shakespeare and John Adams to suggest that the dead are often idealized, he settles down to criticism based on whether or not the DSM-III helped or harmed the profession and Spitzer's role in that process.  Ghaemi comes down firmly on the side of harm because an unscientific approach to the diagnostic criteria for major depressive disorder has resulted in a lack of reliability and validity.  He uses the often quoted kappa score of 0.32 for diagnostic reliability of major depressive disorder in DSM-5 field trials as the main source of evidence, as well as the fact that the diagnostic criteria are unchanged since DSM-III.

Ghaemi suggests that his viewpoint is unique because unlike other eulogists, he had no personal connection with Spitzer and therefore can speak "in forthright recognition of fact from the impersonal perspective of another generation."  I am closer to Ghaemi's generation than Spitzer's and can make the same claim, but come to an entirely different set of conclusions.

I don't see Spitzer's efforts as being as corrosive as Ghaemi does, probably because I recognize the fact that there will never be a set of written diagnostic criteria that are perfect, based on science, and unambiguous.   But before I address the scientific, let me take on the rhetorical.  I would hardly blame Spitzer for the fact that the DSM criteria for depression have changed "hardly an iota" in the intervening 40 years since DSM-III.  Over that same time span there have been hundreds if not thousands of articles on the reliability of the major depressive episode diagnosis, as well as articles that analyze the symptoms according to that diagnosis.  There have been articles on standardizing various psychiatric and psychological instruments to detect major depression.  In fact, one of the rating scales basically copies the DSM criteria and asks the patient to rate on a 0 to 3 point scale - the percentage of days that they experience the symptoms. The PHQ-9 has become the standard for depression diagnosis in many primary care clinics.  There is also the fact that Spitzer's original DSM-III effort resulted in much higher reliability figures - a kappa of 0.72 to be exact (2).

There is also the issue that there have been two intervening Task Forces for DSM-IV and now DSM-5.   The Chair of the DSM-IV Task Force has since become a prominent critic of the DSM process and psychiatry in general.  I may have missed it, but at the time that Task Force was convened, I did not notice him or other members advocating for major changes to the major depression diagnostic criteria.  These are supposedly the top minds in the field.  Highly motivated academics with one axe or another to grind.  The idea that everyone would defer to Dr. Spitzer based on his original approximate efforts seems unrealistic to me.  More than a few people would have noticed his bungled and unscientific approach.

My major problem is using a single reliability figure as the grounds for this criticism.  Every year outpatient based psychiatrists can see up to a thousand new people a year.  They may find that up to 50% of those patients have had a life-long sleep disturbance.  Many can recall nightmares and sleep terrors as children.  Another 20-30% will have generalized anxiety or social anxiety since childhood.  In some there will be a performance based anxiety that is comorbid with the social anxiety.  Another 10-20% will have post-traumatic stress disorder to some degree.  About one-third will have a significant substance use problem.  These percentages will vary by clinic location and referral base.  The majority will be referred for a diagnosis and treatment recommendations for depression.  A substantial number of people with depression have comorbid anxiety and anxious temperaments.  I don't think it is a stretch to say that on any given day, many of the identified depressives will identify themselves as primarily anxious.  It is not unexpected to find that many patients don't really understand the difference between anxiety and depression or they will overtly say that they are the same problem - indistinguishable from one another.  Unless there is a clear differentiating factor like a manic episode, the postpartum state, or psychotic symptoms I would not expect that anxiety and depression are distinct disorders for most people.  At the minimum anxiety might morph into depression, but in most cases they are coexisting chronic conditions.  A low kappa in this situation should be expected and not a shock.

Does that mean that psychiatrists should be wringing their hands and blaming Spitzer for it?  Neither response is appropriate.  Psychiatrists are highly successful in diagnosing and treating mental illness, not because of a DSM manual, but because of clinical training.  When it comes to anxiety and depression there are no known ways to parse all of the symptomatic possibilities.  The human brain is designed to realize all of the possible combinations of human experience.  Why would we expect it to be different when it comes to experiencing anxiety and depression?  The only chance that a psychiatrist has to make sense of the world is a number of patterns of diagnoses based on their training and practice experience that they can match against the patient they are currently seeing.  These patterns guide the diagnosis and treatment plan.  A clinically astute psychiatrist is not plowing through the interview to see if the patient "meets criteria".  A clinically astute psychiatrist carefully attending to the patient's conscious state and trying to figure out how they can be helpful.  That includes figuring out the real problems and prioritizing them in a complex matrix psychiatric and medical problems.  None of that flows from the DSM and none of that resembles research based on lay people interviews using DSM criteria.

In closing, any commentary on Dr. Spitzer should include his role in eliminating homosexuality from the diagnostic manual.  This detail and how it occurred is never taught to residents.  I had to learn it from public radio many years after residency.  This detail is significant any way you cut it.  It invites criticism that monolithic psychiatry is currently moving too slow in other areas or that monolithic psychiatry was just responding to public pressure.  There is also criticism directed at Dr. Spitzer for a paper based on self report that was withdrawn years later on this same issue.  There are always advocacy groups seeking publicity by their own spin on the issue.   In my opinion, none of that diminishes that significant achievement that put psychiatry four decades ahead of most people in the United States.  Say what you will about the DSM, that accomplishment alone is enough.  I am thankful that Dr. Spitzer was open minded enough to listen to the advocates and eventually side with them.              


George Dawson, MD, DLFAPA


1:  Nassir Ghaemi.  Commentary:  Dr. Robert L. Spitzer - An impersonal appraisal.  Clinical Psychiatry News.  March 2016. p 12-13.

2:  Riskind JH, Beck AT, Berchick RJ, Brown G, Steer RA. Reliability of DSM-III diagnoses for major depression and generalized anxiety disorder using the structured clinical interview for DSM-III. Arch Gen Psychiatry. 1987 Sep;44(9):817-20. PubMed PMID: 3632255.

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

Observations from Amazon on DSM-5 sales

As anyone reading the newspapers has heard, the DSM-5 went on sale earlier this year amidst a cacophony of DSM bashing and bashing of the profession in general.  The most vehement critics also exhorted the public to not buy this evil book that would lead to the squandering of billions of healthcare dollars and leave millions hopelessly misdiagnosed and taking expensive unnecessary drugs.  In some cases that I have recorded on this blog the criticism was even more extreme.  Now that the DSM-5 has been out for several months I asked myself what the outcome of all of that bad press has been?  Like thousands of my colleagues, I have picked up a copy and glanced at it from time to time.  It certainly has not lead to any revolution in psychiatric practice or changed anyone's clinical interviewing or diagnostic process.  In fact I have talked with many psychiatrists in the past several months and none of my conversations has touched on the DSM-5.  What are the facts of the release after all of the pre-release spin?

First of all, the predicted apocalypse has not happened.  I should say the apocalypse happened but it was 30 years ago when the managed care industry essentially converted mental illness into "behavioral health" and began to restrict access to psychiatric care, inpatient and medical care, psychotherapy, and certain medications to people with severe mental illnesses.  The predicted apocalypse in response to the DSM-5 did not happen because as I have been saying all along, the DSM has never been the problem.  Mental health care can be denied as easily on the basis of a DSM-5 diagnosis as a DSM-IV diagnosis.  A diagnostic manual is partially relevant only for people who are trained to use it.

That said, is there any way to estimate whether people are buying it or not?  I heard a sales estimate e-mailed by a colleague that suggested brisk sales, but did not have permission to quote him so I started to look for public sources of data on DSM-5 sales.  I went to the usual New York Times Bestseller List and could not find it listed.  I could not really find any academic books listed there so I wonder if there is not another list.  I thought that Amazon would be the next logical stopping point and I did find some data there.  I was looking for data in number of units actually sold and I could only find that as proprietary data that somebody would sell to me.  I did find it as # 8 in Best Sellers of 2013 so far.  This link shows it has been in the Top 100 books for 167 days but that it has fallen to the number 4 position.  Interestingly the Publication Manual of the American Psychological Association had been on the same list 8 times as long.  I also found it in a sequential list of DSM-5 products and related variants including 2 books about the DSM-5 by Allen Frances, MD.  It made me think about obvious conflict of interest considerations in the psychiatry criticism industry that are never mentioned when they get free press.  If somebody can suggest that I have been getting a free lunch from a pharmaceutical company when I haven't seen a drug rep in over 25 years, they should at least point out that somebody can currently make money - possibly even a good amount of money by criticizing psychiatry regardless of whether or not that criticism is remotely accurate.

That is all I have so far.  If you have reliable public data on the actual sales of this manual and would like me to post it here, please send me the information.   I have requested the actual sales figures in an APA forum but I doubt that anyone will provide them to me.  The APA is a very conservative organization and I doubt that they would want you to see those sales figures posted here, even if if this is probably the only public forum that takes a very skeptical look at all of the critics of the DSM-5 and psychiatry in general.

George Dawson, MD, DFAPA

To the Left and the Right of Dr. Frances

Allen Frances continues to erect his wall of criticism of DSM-5.  He shows no sign of slowing down even after the DSM-5 was released.  He has written a list of 18 problems in the Psychiatric Times that he characterizes as "glaring mistakes in wording and coding."  He believes that there were "egregious mistakes on almost every page I read."  That is a curious counterpoint to the opinion I heard recently from Jon Grant, MD when he presented the history, process, and details of the development of DSM-5. While Dr. Frances has undeniable DSM-IV experience there is always plenty of room for disagreement.  He comments that he has limited time for a detailed read of DSM and I have even less, so I will concentrate on 2 of his 18 points to illustrate what I mean.

Intermittent Explosive Disorder - Dr. Frances main complaint about this diagnosis is that is "lacks the needed exclusions to exclude the other more common causes of violent behavior."   The diagnostic criteria actually contains the exclusion:

F.  The recurrent aggressive outbursts are not better explained by another mental disorder.....and are not attributable to another medical condition.....or to the physiological effects of a substance.

Specific examples are given and there is also an exclusion for adjustment disorders in children.  The actual number of exclusionary diagnoses listed are essentially the same as DSM-IV and the discussion in the differential diagnosis is more extensive (p 612-613).  My problem is that I don't think this diagnosis actually exists.  That statement comes from over two decades of experience in acute care inpatient psychiatry, community psychiatry, and hospital psychiatry.  These are all settings on the front lines of aggressive behavior.  When the police encounter aggression and there is any question of an intoxication, medical problem, or mental disorder associated with that behavior - those people are brought in to settings where acute care psychiatrists are  involved.  In my experience of assessing extreme aggression up to and including homicide I have never seen a single case where the outbursts were not better explained by another mental disorder.  I don't agree that the exclusion criteria are any different.  I don't believe that this disorder exists.  If it does, the prevalence is so low that this acute care psychiatrist has not seen it in thousands of evaluations of aggressive behavior.

Mild Neurocognitive Disorder - Dr. Frances complaint about this diagnosis is "so impossibly vague that it includes me, my wife and most of our friends.  It will cause unnecessary worry and a rush to useless and expensive testing."

As I read through these criteria I have a much different perspective.  For about 10 years I ran a Geriatric Psychiatry and Memory Disorders Clinic where we did comprehensive assessments of patients with cognitive problems.  I worked with a nurse who would collect detailed information on patient's functional and cognitive capacity before they came into the clinic for my assessment.   A significant number of those patients had a strictly subjective complaint about their memory or cognition.      A large percentage of these patients did not have any insight into the severity of their problem and their typical assessment was: "My memory is no different than any other 60 or 70 year old."  Even though we had generally spent about three hours of assessment time with each patient, at the end of my evaluation we often did not have a clear diagnosis.  We would stick with that person until we did and often times the outcomes were surprising.  We had striking examples of chronic delirious states where the patient was given a diagnosis of dementia based on on neuropsychological testing, and with treatment and reassurance we observed their cognition to clear completely and they were restored to normal cognitive function.

I see the diagnosis of Mild Neurocognitive Disorder as a portal to that level of care.  Based on the list of 10 brain diseases and other medical conditions listed as specifiers the authors of this criteria clearly had that intent.  It is clear to me that any clinic with a high standard of care for patients with cognitive disorders like my clinic had can use this diagnosis both as part of the continuum to more Major Neurocognitive Disorders associated with progressive neurodegenerative dementias and to provide high quality assessments for patients with concerns about any cognitive changes.  Keep in mind that the typical managed care model would use a crude screening test and possibly refer for other psychological testing.  There might not be a physician in the loop who can make the necessary assessments and diagnoses.  Current research in this area also points to the need to identify patients as early as possible, especially as treatments become available.

On these two points I guess I am to the right of Dr. Frances on Intermittent Explosive Disorder and to the left on Mild Neurocognitive Disorder.  But I think the entire argument misses the mark if we think about the issue of psychiatric diagnosis and where the DSM fits in.  Any DSM cannot be used like a phone book to classify hundreds of different presentations to a Memory Disorder and Geriatric Psychiatry Clinic.  The unique conscious states of those individuals and their relative levels of impairment can only be determined by a comprehensive evaluation by a physician who is knowledgeable in all of the possible brain diseases that are suggested as etiologies.  Apart from the obvious increase in complexity for anything that is determined by a central nervous system, getting a diagnosis of Mild Neurocognitive Disorder is no different than getting a diagnosis of "Neck pain" or "Ankle pain" from a primary care physician.  And yes - those primary care diagnoses are very common.

The idea that there are precise criteria that can be written down and applied to make definitive diagnoses is a common misconception of the DSM and other diagnostic schemes.  To emphasize that point, I will end with a quote from Harold Merskey, FRCP, FRCPsych:

"Medical classification lacks the rigor either of the telephone directory or the periodic table."

That is all medical classification and not just the DSM-5.   A good starting point toward realizing the truth in this quote is to stop looking at the DSM-5 like it is a phone book.  You don't get a psychiatric diagnosis from the DSM-5.

You get a psychiatric diagnosis from a psychiatrist.

George Dawson, MD, DFAPA

Merskey H. The taxonomy of pain. Med Clin North Am. 2007 Jan;91(1):13-20, vii. PubMed PMID: 17164101