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". 

Even more DSM bashing - is it a fever pitch yet?

Just when you think you have seen it all, you run into an article like this one in The Atlantic.  A psychotherapist with a long antipsychiatry monologue.  It is written in interview format with psychotherapist Gary Greenberg as the discussant.  I thought it was interesting because the title  describes this diatribe as the "real problems" with psychiatry.  Of course what he writes about has nothing to do with the real problems that specifically are the rationing and decimation of psychiatric services by managed care companies and the government.  The entire article can be discredited on a point by point basis but I will focus on a few broad brush strokes.

The author here spins a tale that the entire impetus for a diagnostic manual and a biomedical orientation for psychiatry is strictly political in nature and it has to do with wanting to establish credibility with the rest of medicine.  That is quite a revision of history.  Psychiatry pretty much exists now because psychiatrists would take care of the problems that nobody else wanted to.  I have immediate credibility when another physician is seeing a person with a mental illness, they don't know what to do about it, and I do.  It is less clear today, but psychiatry professional organizations were asylum focused and the goal was to treat people in asylums initially and then figure out a way to get them back home.  Part of the psychiatric nosology was based on the people who would get out of asylums at some point and those who did not.  The credibility of psychiatry has nothing to do with a diagnostic manual.  It has to do with the fact that psychiatrists have a history of treating people with serious problems and helping them get well.  There is no discussion of how the numbers of people institutionalized in the 1950s and 1960s fell to the levels of current European levels as a result of psychiatric intervention that included the use of new medications but also a community psychiatry movement that was socially based. (see Harcourt Figure II.2)

The author uses the idea of "chemical imbalance" rhetorically here as further proof that psychiatrists are using a false premise for political purposes.  He presumes to tell his readers that during the time he is giving the interview there is some psychiatrist out there using the term chemical imbalance to convince a patient to take antidepressants.  Since I have never used that term and generally discourage it when patients bring it up, I wonder if he is right.  Any psychiatrist trained in the past three decades knows the situation is much more complex than that.  Eric Kandel describes the situation very well in his 1979 classic article on "Psychotherapy and the Single Synapse".  Any antipsychiatrist using "chemical imbalance" against psychiatry in a rhetorical manner suggests that there is no biomedical basis for mental disorders.  There should be nobody out here who believes that is true and in fact this article acknowledges that.

The basic position here is to deny that anything psychiatric exists.  Psychiatrists  don't know what they are doing.  Psychiatrists are driven by the conflict of interest that nets them "hundreds of millions of dollars".  He doesn't mention how much money he makes as an outspoken critic of psychiatry.  He tries to outflank his rhetoric by suggesting any psychiatrists who disagrees with him and suggests that it is typical antipsychiatry jargon is "diagnosing him".   He doesn't mention the fact that antipsychiatry movements are studied and classified by philosophers.

I think the most revealing part of this "interview" is that it appears to be orchestrated to enhance the author's rhetoric.  The evidence for that is the question about "drapetomania" and implying that has something to do with coming up with DSM diagnoses and the decision to drop homosexuality as a diagnostic category.   That is more than a stretch that is a clear distortion and of course the question is where the interviewer comes up with a question about "drapetomania".  I wonder how that happened?

This column is an excellent ad for the author's antipsychiatry work.  Apart from that it contains contains the standard "chemical imbalance" and psychiatric disorders are not "real illnesses".  To that he adds the conflicting positions of saying there appear to be biological correlates of mental disorders but they would never correlate with an existing diagnosis and the idea of a chemical imbalance metaphor is nonsense.  He uses colorful language to boost his rhetoric:  "They'll (those wacky psychiatrists - my  clarification) bob and weave, talk about the "living document," and unleash their line of bullshit." 

His conclusory paragraph and the idea to "take the thing (DSM) away from them" has been a common refrain from the DSM critics.  In fact as I have repeatedly pointed out, there is nothing to stop any other organization from coming up with a competing document.  In fact, sitting on my shelf right now (next to DSM-IV) is a reference called the Psychodynamic Diagnostic Manual.  It is listed as a collaborative effort of six different organizations of mental health professionals.  It was published 12 years after the last edition of the DSM - it is newer.  I have texts written by several of the collaborators of this volume.  When I talk with psychiatrists from the east coast, they frequently ask me about whether or not I am familiar with the volume.   My point here is that if the author's contentions about the reality basis of DSM diagnoses are correct, it should be very easy to come up with a different system.  I encourage anyone or group of people to develop their own diagnostic system and compete with the DSM.

So the last minute attacks on psychiatry with the release of the DSM seem to be at a fever pitch.  The myth of the psychiatric bogeyman is alive and well.  Add The Atlantic to the list of uncritical critics of psychiatry.

George Dawson, MD, DFAPA

1.  Hope Reese.  The Real Problems with Psychiatry.  The Atlantic.  May 2, 2013.

2.  Bernard E. Harcourt.  From the asylum to the prison: rethinking the incarceration revolution.  The Law School, University of Chicago, 2007.

3.  Psychodynamic Diagnostic Manual (PDM).  A collaborative effort of the American Psychoanalytic Association, International Psychoanalytic Association, Division of Psychoanalysis (38) of the American Psychological Association, American Academy of Psychoanalysis and Dynamic Psychiatry, National Membership Committee on Psychoanalysis in Clinical Social Work.  Published by the Alliance of Psychoanalytic Organizations.  Silver Spring, MD (2006).

4.  Kandel ER. Psychotherapy and the single synapse. The impact of psychiatric thought on neurobiologic research. N Engl J Med. 1979 Nov 8;301(19):1028-37. PubMed PMID: 40128.

Nature Takes A Shot at DSM5 – Spectrums Only Get You So Far

"The Catholic Church changes its pope more often than the APA publishes a new DSM." (reference 1)

I was disappointed to see another shot at the DSM, this time on my Nature Facebook feed.  I suppose with the impending release it is a chance to jump on the publicity bandwagon.  I will jump over numerous errors in the first paragraph (David Kupfer – modern day heretic?!) and get to the main argument.  The author in this case makes it seem like seeing psychopathological traits on a spectrum is somehow earth shaking news and yet another reason to trash a modest diagnostic manual designed by psychiatrists to be used as a part of psychiatric diagnostic process. 

In evaluating this article the first question is the whole notion of continuums.    The idea has been there for a long time and this is nothing new.  Just looking at some DSM-IV major category criteria like major depression, dysthymia, and mania and just counting symptoms using combinatorics you get the following possibilities:

Major depression - 20 C 5 = 15,504

Manic episode - 15 C 3 = 455

Dysthymia - 2 C 10 = 45

Mixed - 20 C 5 + 15 C 3 = 15,959

That means if you are following the DSM classification and looking just at the suggested diagnostic combinations you will be seeing something like 16,004 combinations of mood symptoms just based on a categorical classification.  Superimposed reality can expand that number by several factors right up to the point that you have a patient who cannot be categorically diagnosed. If you add all Axis II conditions with mood sx - there is another large expansion in the number of combinations.  The sheer number of combinations possible should suggest at some point that the discrete categories give way to a frequency distribution.  The only problem of course (and this is lost or ignored by all managed care and political systems) the clinician is treating an individual patient with certain problems and not addressing the entire spectrum of possibilities.  The other reality is that if you put a point anywhere on the spectrum including the Nature blog's  mental retardation-autism-schizophrenia-schizoaffective disorder-bipolar and unipolar disorder spectrum - you essentially have a categorical diagnosis.

In a recent article, Borsboom, et al use a graphing approach to show the relationship between the 522 criteria (simplified to 439 symptoms) of 201 distinct disorders in the DSM-IV.  The authors demonstrate that these symptoms are highly clustered relative to a random graph and go on to suggest that their network model currently account for the variance in genetics, neuroscience, and etiology in the study of mental disorders.  Their figure below is reproduced in accordance with the Creative Commons 3.0 license. (click to enlarge).

 For the example given by the author’s example – schizophrenia with obsessive traits, we still need to make that characterization in order to proceed with treatment.   The diagnostic categories “schizophrenia” and “obsessive compulsive disorder” and “obsessive compulsive personality disorder” are still operative.  What does saying that there is a “continuum” or “spectrum disorder” add?   In initial evaluations psychiatrists are still all looking for markers of all of the major diagnostic categories and listing everything that they find.  The treatment plan needs to be a cooperative effort between the psychiatrist and patient to treat the problems that are affecting function and leading to impairment.  The idea that there will be a magical genetic and brain imaging test that will result in a “proper clinical assessment” at this point is a pipe dream rather than a potential product of a diagnostic manual.  The limitations of the spectrum approach are also evident in this article that points out the failed field trials attempting to use a dimensional approach for personality disorders.

George Dawson, MD, DFAPA

1.  Adam D. Mental health: On the spectrum. Nature. 2013 Apr 25;496(7446):416-8. doi: 10.1038/496416a. PubMed PMID: 23619674

2.  Borsboom D, Cramer AO, Schmittmann VD, Epskamp S, Waldorp LJ. The small world of psychopathology. PLoS One. 2011;6(11):e27407. doi: 10.1371/journal.pone.0027407. Epub 2011 Nov 17. PubMed PMID: 22114671

ADHD - The Scientific Evidence versus the Political Hype

I attended a day long seminar by Russell Barkley, PhD.  It is part of my ongoing mission of seeing the experts in person who I have read and collected in my library over the past 30 years.  My earliest exposure to Dr. Barkley's work was the book Hyperactive Children that I acquired while I was in Medical School and used when I was treating children in the first clinic I worked in as a psychiatrist.  Interestingly he was working at the same medical school I had attended.  Dr. Barkley has an impressive surveillance system for current literature and in the seminar was presenting work that had literally been published or put into prepublication the day before.  His scholarship is impressive and he is one of the most widely published authors in the field.  He has a clear scientific approach and does not recommend treatments that have not gone through randomized and blinded clinical trials.  He gave many examples of ADHD treatments that seemed effective until the raters were blinded to the treatment or the methods were used by researchers who had no vested interest in the outcome.

All of his information was presented on PowerPoint as is the standard.  His PowerPoint slides were information dense, frequently presenting dimensions and data points from several studies on the same line.

A few of the highlights that you will not read in the New York Times:

1.  On the "overdiagnosis" issue - at this time about 40% of kids and 10% of adults with the disorder are treated.
2.  On the DSM issue - the categories of ADHD are going away.  Like categories of schizophrenia and autism spectrum disorder they are not unique entities.   This of course runs counter to the usual DSM criticism that there is a proliferation of diagnostic categories   Another positive was that the age of onset criteria is changing from age 7 to age 12.  Barkley points out that an age cutoff for a developmental process is arbitrary and suggested a further change to "onset in childhood or adolescence".  On the other hand, it does appear that the committee in charge is responding to political pressure from the government and insurance companies to not make any changes that would increase the prevalence of the disorder.  He presented clear criteria that would improve the diagnosis of ADHD in adults that will apparently not be included or possibly on a parenthetical basis.
3.  The problem with the treatment of children is not overtreatment, but that fact that most children who need treatment discontinue their medications as teenagers.
4.  The resulting complications of untreated ADHD are significant from an educational, public health, and psychiatric perspective.  As one example, untreated ADHD is associated with high risk of dropping out of school.  Every person who drops out and does not complete school represents a cost of $450K to the community.
5.  Stimulant medications have a 40 year record of use and there have been over 350 studies documenting the efficacy and safety.  They have the greatest effect size of any psychiatric medications and that includes up to 90% response rates across all stimulants.
6.  Response to treatment is robust and the best of any psychiatric disorder.  Evidence based studies show that patients treated with stimulants show improved outcomes across 20 parameters and that treatment with atomoxetine is associated with improvement across 23 parameters.
7.  These medications have an unprecedented safety record.
8.  There is a potential steep cost in many areas of not adequately treating the disorder.

It is very disappointing to hear that the DSM committee may be yielding to political pressure when it comes to implementing new evidence based DSM criteria particularly give the poor quality of these arguments.  A professional organization should be above political influence when it comes to scientific findings and this revision of criteria was supposed to be based on science.  The APA does have a long history of not providing any resistance to the managed care industry or government initiatives to reduce the quality of psychiatric care in favor of the managed care industry.  If true it will be ironic that the ADHD section of the DSM5 will be be directly influenced by the usual managed care forces and that they are aligned with all of the media rhetoric about the proliferation diagnoses and increased prevalence.

So the usual media hype is wrong - psychiatrists and pharmaceutical companies are not plotting to put more people on medication.  The government, managed care companies, and the anti-biological antipsychiatrists are trying to keep them off even when they are indicated.  In that political divide - the science is left out.

George Dawson, MD, DFAPA

Dr. Russell A. Barkley, PhD.  Official Web Site.

Dr. Russel A. Barkley, PhD.  Professional Workshop on ADHD.  ADHD Across the Life Span: Diagnosis, Life Course, Management, and Comorbidity.  Minnetonka, Minnesota.  Thursday November 15, 2012.

International Consensus Statement on ADHD (excerpt) - read this statement signed by scientists explaining that this diagnosis is not controversial and that the percentage of patients treated is about the same in the past decade.