DSM-5.0

I finally saw a copy of the DSM-5 today.  It was sitting on a table at a course on the DSM put on by the Minnesota Psychiatric Society.  The DSM-5 portion of the course was about 3 1/4 hours of lectures (98 information dense PowerPoint slides) by Jon Grant, MD.    Dr. Grant explained that he was in a unique position to provide the information because he and Donald Black, MD had been asked by the American Psychiatric Association (APA) to write the DSM-5 Guidebook.  In this unique position they were privy to all of the notes, minutes, e-mails and documents of the DSM Work Groups.  In the intro it was noted that Dr. Grant had written over 150 papers and 5 books.  He was probably one of the best lecturers I have ever seen with a knack to keep the audience engaged in some very dry material.  There were times that he seemed to be riffing like a stand up comedian.  The content was equally good.  I thought I would summarize a few of the high points that I think are relevant to this blog.

The first section was an overview of the history.  The original DSM was published in 1952, but before that there were several efforts to classify mental disorders dating back to ancient times.  Some of the systems persisted for hundreds of years.  He credited Jean-Etienne Esquirol (1772-1840) as one of the innovators of modern classification.  The philosophical approaches to the subsequent DSMs were reviewed and they generally correlate with the theories of the day.

The development of DSM-5 began in 1999.  The original goals included the definition of mental illness, dimensional criteria, addressing mental illness across the lifespan, and to possibly address how mental disorders were affected by various contexts such as sex and culture.  Darrel Regier, MD was recruited from the NIMH to coordinate the development of DSM-5 in the year 2000.  Between 2003 and 2008 there were 13 international conferences where the researchers wrote about specific diagnostic issues and developed a research agenda.  This produced over 100 scientific papers that were compiled for use as reference volumes.  As far as I can tell the people on the ground on this issue was the DSM Task Force and the Work Groups.  The Task Force addressed conceptual issues like spectrum disorders, the interface with general medicine, functional impairment, measurement and assessment, gender and culture and developmental issues.  The Work Groups met weekly or in some cases twice a week by conference call and twice a year in person.  The work groups had several goals including revising the diagnostic criteria according to a  review of the research, expert consensus and "targeted research analyses".  No cost estimate of this multi-year infrastructure was given.

Like any volume of this nature the originators had some guiding principles including a focus on utility to clinicians, maintaining historical continuity with previous editions, and the changes needed to be guided by the research evidence. The most interesting political aspect of this process was the elimination of people closely involved in the development of DSM-IV in order to encourage "out of the box" thinking.  This was a conscious decision and I have not seen it disclosed by some of the professional critics out there.

Final approval of the DSM occurred after feedback was received through the DSM-5 web site.  There were thousands of comments from individuals, clinicians and advocacy organizations.  Field trial data was analyzed and discussed.  A scientific committee reviewed the actual data behind the diagnostic revisions and confirmed it.  Hundreds of expert reviewers considered the risks in revising the diagnoses.  The APA Assembly voted to approve in November 2012.

Some of the criticisms of the DSM-5 were discussed in about 4 slides.  Dr. Grant was aware of all of the major criticisms and I have reviewed most of them here on this blog such as the issue of diagnostic proliferation.  Dr. Grant's lecture contained this graphic for comparison:

Rather than repeat what I have already said, it should be apparent to anyone who knows about this process that it was open, transparent and involved a massive effort of the part of the psychiatrists and psychologists involved.  It should also be apparent that the DSM process was clinically focused and that safeguards were in place to consider the risk of diagnostic changes.  I have not seen any of that discussed in the press and don't expect it to be.  For all of you DSM-5 conspiracy theorists, more than enough people involved without a sworn oath to assure that no secret would ever be kept.

What about the final product?  The DSM-5 ends up including 19 major diagnostic classes.  Some of the highlights include moving some disorders around.  Obsessive-compulsive disorder and Post Traumatic Stress Disorder were moved out of the Anxiety Disorders section to their own separate categories.  Bipolar and Depressive Disorders each have their own diagnostic class instead of both being placed in a Mood Disorders class.  Adjustment Disorders have been moved into the Trauma and Stress Related Disorders class and there are two new subtypes.  As previously noted here, all of the Schizophrenia subtypes have been eliminated.  The Multiaxial System of diagnosis has been scrapped.  One of the changes impacting the practice of addiction psychiatry is the elimination of the categories of Substance Abuse and Substance Dependence and collapsing them into a Substance Use Disorder.  Panic attacks can now be used as a symptom of another disorder without having to specify that the person has panic disorder and that is a pattern I have observed over the course of my career.  The controversial Personality Disorders section is unchanged but there is a hybrid diagnostic system that includes dimensional symptoms, the details of which (I think) are in the Appendix.  Mapped onto all of the diagnostic classification and criteria changes are a number of subtypes and specifiers as well as a number of ways to specify diagnostic certainty.  As with previous editions since DSM-III there is a mental disorder definition that indicates that behavior or criteria are not enough.  There must be functional impairment or distress.  The definition specifies that socially deviant behavior or conflicts between the individual and society do not constitute a mental illness unless that was the actual source of the conflict.

The overall impression at the end of these lectures was that this was a massive 18 year effort by the APA and hundreds and possibly thousands of volunteer psychiatrists and psychologists.  None of those volunteers has a financial stake in the final product.  Many of the criticisms were addressed in the process and many of the critics have a financial stake in the DSM-5 criticism industry.  The criticisms of the DSM-5 seem trivial compared with the process and built in safeguards.  The DSM-5 was also designed to be updated online instead of waiting for another massive effort to start to make modifications, hence this is not DSM-5 but DSM-5.0.

If Dr. Grant is lecturing in your area and you are a psychiatrist or a psychiatrist in training, these lectures are well worth attending.  If you have a chance to look at his Guidebook, I think that it will be a very interesting read.

George Dawson, MD, DFAPA

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". 

Crickets from the APA

"The best way to predict the future is to create it." - Peter Drucker

The annual convention is approaching and the American Psychiatric Association (APA) has decided to train a few psychiatrists from each district branch to teach about the new DSM5.  They think that is sufficient to fill the demand from organizations and groups who want assistance with DSM5 training and implementation.  They also think that the threat of litigation is enough to protect the DSM copyright and prevent other self declared trainers from going around the country and training people about the DSM5.  That is more critical than you might think.  Let me explain why both of these thoughts are problematic wrong and describe a more optimal course of action that could still be implemented before the May convention.

First of all let me say that the ideas I am posting here are not new.  I have inquired directly from the APA as a member both at their Washington Offices and through my District Branch (DB).  The lack of response prompted the “Crickets” title from the APA because cricket chirping is about all I am hearing about any initiative other than the APA’s original plan.  There are many sources of failure possible by restricting the training.  The obvious one is that psychiatrists are busy.  The failed billing and coding system generally means that psychiatrists are seeing a lot of patients and spending even more time on billing, coding, and documentation.  That leaves very little time each week to study for recertification exams, train future psychiatrists and medical students, and participate in other professional activities.  Given how thin psychiatrists and other physicians find themselves spread, it might be reasonable to have a bureau of trained DSM5 experts at each DB to cover the potential demand.

I first got interested in this issue when a large health care organization asked me about the availability of consultants to assist them in their nationwide implementation.  The DSM IV is currently implemented in their electronic medical record (EMR).  Several calls directly to the APA did not produce any results.  I identified myself as a member and that did not make a difference.  I contacted my excellent DB Executive who I had worked with during my term of being the DB President.  She is extremely knowledgeable and widely networked within the organization.  The question I proposed was whether the APA would consider opening up the convention session to all psychiatrists through the DB and certifying anyone who has taken the course.  Still no response.

Absent the response I have the following suggestions about how to train DSM5 trainers in the interest of the APA and its mission and preserve the copyright integrity of the DSM5:

1.  Expand the training in May to all DBs and to as many psychiatrists as want to take the training.

 

2.  Provide password access to all of these psychiatrists to the DSM5 web site for the purpose of ongoing learning.  The DSM5 site was quite good in providing the rationale for suggested changes and prospective trainers could benefit from ongoing access to this material.

3.  Provide educational materials (PowerPoints) to all of the trainers through access to a training web site.

4.  Develop a course specific to administrators and companies who need IT implementation information and have that readily available.

5.  License DSM5 to corporations in the same way that psychiatrists with online subscriptions can access it.  UpToDate has provided a good example of the continuously updated online reference rather than serial textbooks being the direction forward.  There should be no need for update cycles and massive political events to herald updates.  The DSM and all psychiatric guidelines need to be systematically reviewed and updated if APA technology is to be seen as the definitive reference for the biomedical diagnosis and treatment of major mental disorders.  Updating every 10-20 years will not survive in the day of Internet technology.  There is also a lot less drama involved when UpToDate updates its content.  That is consistent with being a resource for physicians and by physicians.  

All of these recommendations can be done and anything less than following through on these recommendations leaves the APA seriously compromised and not competitive in the future.

George Dawson, MD, DFAPA