DSM5 Dead on Arrival!

That's right.  The latest sensational blast on the fate of that darling of the media the DSM5 is that it is dead on arrival.  That recent proclamation is from the Neuroskeptic and it is based on the analysis of  criticism of DSM5 criteria for Generalized Anxiety Disorder (GAD).  OK - the original proclamation was "increasingly likely DOA".  I confess that at this point I have not read the original article by Starcevic, Portman, and Beck but the Neuroskeptic provides significant excerpts and analysis.

The broad criticism is that the category has been expanded and is therefore less specific.  The authors are concerned that this will lead to more inclusion and that will have "negative consequences."  The main concern is the "overmedicalization" of the worried and the dilution of clinical trails.  All this gnashing of the teeth leads me to wonder if anyone has actually read the Generalized Anxiety Disorder DSM5 criteria that is available on line.  The proposed new criteria, the old DSM-IV criteria and the rationale for the changes are readily observed.  The basic changes include a reduction on the time criteria for excessive worry from 6 months to three months, the elimination of criteria about not being able to control worry, and the elimination of 4/6 symptoms under criteria C (easy fatigue, difficulty concentrating, irritability and sleep disturbance).  A new section on associated behaviors including avoidance behavior a well known feature of anxiety disorders is included.  The remaining sections on impairment and differential diagnosis are about the same.  The GAD-7 is included as a severity measure although I note that the Pfizer copyright is not included.

So what about all of the criticism?  The "Rationale" tab is a good read on the DSM5 web site.  I can say that clinically non-experts are generally clueless about the DSM-IV features of anxiety especially irritability.  Most psychiatrists have a natural interest in irritability because we tend to see a lot of irritable people.  There has been some isolated work on irritability but it really has not produced much probably because it is another nonspecific symptoms that cuts across multiple categories like the authors apply to cognitive problems and pain.  So I will miss irritability but not much.  Psychiatrists have to deal with it whether we have a category for it or not and hence the need for a diagnostic formulation in addition to a DSM diagnosis (managed care time constraints permitting).

But like most things psychiatric - the worried masses rarely present to psychiatrists for treatment these days.   How likely is it that a busy primary care physician is going to review ANY DSM criteria for GAD?  How likely is it that a person with a substance abuse disorder is going to disclose those details to a primary care physician as a probable cause of their anxiety disorder?  How likely is it that benzodiazepines will be avoided as a first line treatment for any anxiety disorder?  In my experience as an addiction psychiatrist I would place the probability in all three questions to be very low.  It doesn't really matter if you use DSM-IV criteria or DSM5 criteria - the results are the same.

As far as "medicalization" goes, I am sure that somebody (probably on the Huffington Blog) will whip this into another rant about how the DSM5 enables psychiatrists to overdiagnose and overprescribe in our role as stooges for Big Pharma.  But who really has an interest in treating all anxiety like a medical problem?  I have previously posted John Greist's  single handed efforts in promoting psychotherapy and computerized psychotherapy for anxiety disorders even to the point of saying that the results are superior to pharmacotherapy.  In the meantime, what has the managed care cartel been doing?  Although their published guidelines appear to be nonexistent it would be difficult to not see the parallels between approaches that use the PHQ-9 to assess and treat depression and using the parallel instrument GAD-7 in a similar manner.  The problem with both approaches is that they are acontextual and the severity component cannot be adequately assessed.  The goal of managed care approaches to treat depression is clearly to get as many people on medications as possible and call that adequate treatment.  Why would the treatment of GAD be any different?

It should be obvious at this point that I am not too concerned about the DSM5, DSM-IV, or whatever diagnostic system somebody wants to use.  The DSM5 is clearly about rearranging criteria based on recent studies with the sole exception of including valid biological markers for the sleep disorders section.  Like many my speculation is that the ultimate information based approach to psychiatric disorders rests in genomics and refined epigenetic analysis and I look forward to that information being incorporated at some point along the way.

But let's get realistic about why the results of DSM technology are limited.  As it is with DSM-IV and as it will be with DSM5, clinicians are free to interpret and diagnose basically whatever they want.  Even with the vagaries of a DSM diagnosis, I doubt that the majority of primary care treatment hinges on a DSM diagnosis of any sort.  I also doubt that the dominant managed care approach to diagnosis and treatment of GAD depends on a psychiatric diagnosis or research based treatment.  It certainly excludes psychotherapy.  Trying to pin those serious deficiencies as well as overexposure to medication on the DSM and psychiatrists is folly.

George Dawson, MD, DFAPA


1: Gorman JM. Generalized anxiety disorders. Mod Probl Pharmacopsychiatry. 1987; 22: 127-40. PubMed PMID: 3299062.

Myths in the Huffington Post

Let me start out by saying that I have a low opinion of the Huffington Post largely because of its rhetorical approach to psychiatry.  Tales about the pharmaceutical company corruption of psychiatry, ongoing articles about the myth of mental illness, references to very poorly done research that supposedly discredits psychiatry, the idea that the DSM is either a manual for everyman instead of clinical psychiatrists or a book written to manipulate the general public - the Huffington Post has it all and then some.  Interestingly, the Huffington Post lists these postings under "Science" when it is clear that nobody there seems to know the first thing about science or how it differs from personal opinion.  From what I have seen, listing yourself as an authority on science apparently makes it so on the Internet.  "Rhetoric/Politics" would be a much more accurate heading.

Enter Allen Frances commenting in blog form.  I have already responded to one of the Dr. Frances editorials that seem to pop up everywhere.  I find the whole process of taking a scientific debate within a professional society into a public forum somewhat appalling.  In this case, the rhetorical device of applying a decision made about an entirely different process - withdrawing a paper that the author believes was incorrectly done due to a methodological error ( one that is common to much psychosocial research) to the DSM process seems rhetorical to me.  That occurs after the process has been thoroughly politicized in the media.

The arguments themselves are either red herring or they make it seem like the very public decrying of the DSM process has shamed the APA into not declaring grief and psychosis risk to be diagnoses.  The public will never know what the APA process would have decided on these issues and of course every critic wants to take credit for exposing the APA as a group of money grubbing scoundrels whose only mission in life is to appease Big Pharma or generate huge revenue for the organization.

I wish I could count on the public to be as skeptical of these opinions as they are of other political opinions.  Unfortunately after 25 years of practice, I can say with certainty that only a few people know what a psychiatrist is or how they are trained.  Today there is more misinformation than ever about psychiatry via the Internet.

As a reminder, the DSM is for clinical psychiatrists and psychiatric research.  Reading criteria without the associated training is not the same thing as making a diagnosis.  There are many nonpsychiatric mental health professionals and many nonpsychiatric physicians.  In fact, the bulk of psychotropic medications in this country are prescribed by nonpsychiatric physicians.  Access to psychiatrists is tightly controlled by managed care companies and state governments. It is difficult to see a psychiatrist initially and over time.  These same managed care organizations control who is admitted to and discharged from inpatient psychiatric units and the type of care provided there.

The idea that the APA is an omnipotent organization with the power to manipulate and control the provision of mental health care through out the USA is a myth of massive proportions.  The idea that the DSM is a potential tool for that manipulation is another.

You can probably read about that first on the Huffington Post.

George Dawson, MD, DFAPA

DSM5 - NEJM Commentaries

I highly recommend the two commentaries in the New England Journal of Medicine this week.  The first was written by McHugh and Slavney and the second by  Friedman.  Like Allen Frances they are experienced psychiatrists and researchers and they are likely to have unique insights.  I may have missed it, but I am not aware of any of these authors using the popular press to make typical political remarks about the DSM.  Those remarks can be seen on an almost weekly basis in any major American newspaper.

McHugh and Slavney focus interestingly enough is the issue of comprehensive diagnosis and opposed to checklist diagnoses.  It reminded me immediately that the public really does not have the historical context of the DSM or how it is used.  It also reminded me of the corrosive effect that managed care and the government has had on psychiatric practice with the use of "templates" to meet coding and billing criteria in the shortest amount of time.   Finally it reminded me of the bizarre situation where we have managed care companies and governments combining to validate the concept of a checklist as a psychiatric diagnosis and court testimony by experts suggesting that it is negligent to not use a checklist in the diagnostic process.

McHugh and Slavney summed up in the following three sentences: “Checklist diagnoses cost less in time and money but fail woefully to correspond with diagnoses derived from comprehensive assessments. They deprive psychiatrists of the sense that they know their patients thoroughly. Moreover, a diagnostic category based on checklists can be promoted by industries or persons seeking to profit from marketing its recognition; indeed, pharmaceutical companies have notoriously promoted several DSM diagnoses in the categories of anxiety and depression.” (p. 1854)

In my home state, the PHQ-9 is mandated by the state of Minnesota to screen all primary care patients being treated for depression and follow their progress despite the fact that this was not the intended purpose of this scale and it is not validated as an outcome measure.  The PHQ-9  is copyrighted by Pfizer pharmaceuticals.

The authors go on to talk about the severe limitations of this approach but at some point they seem to have eliminated the psychiatrist from the equation. I would have concerns if psychiatrists were only taught checklist diagnoses and thought that was the best approach, but I really have never seen that. Politicians, managed care companies, and bureaucrats from both are all enamored with checklists but not psychiatrists. They also talk about the issue of causality and how that could add some additional perspective. They give examples of diagnoses clustered by biological, personality, life encounter, and psychological perspectives. Despite its purported atheoretical basis, the DSM comments on many if not all of these etiologies.

Friedman's essay is focused only on the issue of grief and whether or not DSM5 would allow clinicians to characterize bereavement as a depressive disorder. That is currently prevented by a bereavement exclusion and DSM-IV and apparently there was some discussion of removing it. He discusses the consideration that some bereavement is complicated such as in the situation of a bereaved person with a prior episode of major depression and whether the rates of undertreatment in primary care may place those people at risk of no treatment.

There can be no doubt that reducing a psychiatric diagnosis to a checklist loses a lot of information and probably does not produce the same diagnoses. There is also no doubt that the great majority of grieving persons will recover on their own without any mental health intervention. Both essays seem to minimize the role of psychiatrists who should after all be trained experts in comprehensive diagnoses (the kind without checklists). They should be able to come up with a diagnostic and treatment formulation that is independent of the DSM checklists. They should also be trained in the phenomenology of grief and the psychiatric studies of grief and realize that it is not a psychiatric disorder.  If they were fortunate enough to be trained in Interpersonal Psychotherapy they know the therapeutic goals and treatment strategies of grief counseling and they probably know good resources for the patient.

The critiques by all three authors are legitimate but they are also strong statements for continued comprehensive training of psychiatrists. There really should be no psychiatrist out there using a DSM as a "field guide" for prescribing therapy of any sort based on a checklist diagnosis. Primary care physicians in some states and health plans have been mandated to produce checklist diagnoses.  The public should not accept the idea that a checklist diagnosis is the same as a comprehensive diagnostic interview by psychiatrist.

That is the real issue - not whether or not there is a new DSM.

George Dawson, MD DFAPA

McHugh PR, Slavney PR. Mental illness--comprehensive evaluation or checklist?

N Engl J Med. 2012 May 17;366(20):1853-5.

http://www.nejm.org/doi/full/10.1056/NEJMp1202555?query=TOC 

Friedman RA. Grief, depression, and the DSM-5. N Engl J Med. 2012 May

17;366(20):1855-7.

http://www.nejm.org/doi/full/10.1056/NEJMp1201794?query=TOC

Why Allen Frances has it wrong

Allen Frances has been a public critic of the DSM process and as an expert he frequently gets his opinions out in the media.  Today he has an op-ed piece on the New York Times that is a more general version of a more detailed post on the Health Care blog.  His main contention is the stakeholder argument and that is that there are too many stakeholders both public and professional to allow the American Psychiatric Association to maintain its "monopoly" on psychiatric diagnosis.  I will attempt to deconstruct his argument.

He discusses the earlier DSM versions as revolutionizing the field and the associated neuroscience but then suggests that diagnostic proliferation has become a central problem and the only solution is political arbitration.  What about the issue of diagnostic proliferation?  The number of diagnostic entities per DSM are listed below:

DSM-I, 268 entities

DSM-II, 339 entities 

DSM-III, 322 entities

DSM IIIR, 312 entities

DSM-IV, 374 entities

DSM-V,  370 - 400 entities (depending on final form)

In terms of the total diagnostic entities, I have not seen any stories in the media pointing out that the total number of diagnoses may end being less than DSM-IV.  I have also not seen any discussion of major diagnoses where that is clearly true, such as the elimination of schizophrenia subtypes.   Other issues on diagnostic proliferation that are not discussed are the other required diagnostic system in medicine - the International Classification of Diseases 9th Revision or ICD-9.   The recent modification the ICD-10 has undergone a revision and the total number of diagnoses has increased from 14,000 to 68,000 diagnosis codes.  A fourfold increase.  The number of potential codes for a fractured kneecap has gone from 2 to 480 or more than the total potential codes in DSM5. 

I have also not seen any discussion of the role of psychiatrists in making a psychiatric diagnosis.  Psychiatric diagnosis does not depend on looking up a diagnosis in a catalog of symptoms.  It involves being trained in psychopathology and knowing the patterns of these illnesses.  The patterns of psychotic disorders and the other main diagnostic groupings have basically been unchanged across DSMs.  Psychiatrists make clinical diagnoses based on these major groupings and not the total number of diagnostic entities.

Further evidence that the total number of diagnostic categories is unlikely to have any impact on the number of people diagnosed with mental illness in any given year comes from the distribution of diagnostic codes in an outpatient setting. For 2006-2007, there were approximately 58 million ambulatory care visits for mental disorders. 92% of those visits were for 10 major diagnostic categories that have not changed in recent DSM revisions. It is not likely that new diagnostic categories will significantly impact the remaining 8% or 4.8 million visits per year.

In a study more specific to psychiatry, the number of psychiatric ICD-10 codes used in Danish Psychiatric Central Registry.  The data  represented 1,260,097 diagnoses from 1,041,589 discharges of 653,754 patients from in- and outpatient treatment episodes.  Forty nine of the diagnostic codes accounted for 75% of all the diagnoses (Munk-Jørgensen, et al). 

The "medicalization of normality" is another argument.  The media routinely runs stories about the percentage of the population that is "mentally ill" based on DSM diagnoses.  One of the common stories is the estimate that as many as 50% of the population has a DSM diagnosis over the course of the year.  There is never a critical look at that statistic.  The first dimension is whether any percentage should be too high or too low.  For example, would anyone be surprised to learn that 100% of the population has a medical diagnosis in the previous year?  With a high prevalence of gastroenteritis and respiratory infections - probably not.  The second dimension speaks directly to the issue of threshold for an illness.  One of the key papers in this area shows that although the one year prevalence using DSM criteria may be high, limiting the diagnoses to severe disorders reduces the prevalence to 8%.

The use of high prevalence numbers for mental illness based on DSM diagnoses also ignores the extensive Epidemiological Catchment Area (ECA) work that estimated lifetime prevalence.  Readers are generally not told that the methods used include addictive disorders and neurological disorders that cause cognitive impairment.  Would anyone doubt that 32% of adults would report a psychiatric disorder that included an addiction or cognitive impairment at any point in their lifetime?

Similarly there has been the repeated criticism that psychiatrists were going to start treating grief like clinical depression.  I have never seen that approach anywhere in my career spanning psychopathology seminars, journal articles, and continuing education courses.  Any psychiatrist with a clue knows the difference between grief and depression and at some point they have probably been tested on that difference.  What psychiatrists know that is not public knowledge is that a small number of grieving people actually develop a depression that is indistinguishable from clinical depression and it may have to be treated that way.  Knowing the difference is part of psychiatric expertise and you really cannot write it down as sentences in a manual.  In fact, it is a grave  mistake to equate a manual of diagnostic criteria with the clinical expertise and methods of psychiatry.

Dr. Frances correctly points out that the other common media theory that DSM diagnoses are driven by the pharmaceutical industry is a myth.  He continues on to suggest that the public and other mental health professionals somehow have a stake in the DSM and that organized psychiatry has frozen them out.  He concludes: “Psychiatric diagnosis is too important to be left exclusively in the hands of psychiatrists.”  I don’t understand how the specialty who invented the technology, who is trained and tested on it, and who is focused on a comprehensive view of psychopathology that extends beyond it should somehow give way to political considerations.  As he points out – there are always political considerations – even in science.  I would suggest that there is no such thing as “independent scientific review” of anything that psychiatry does.  There are many ways to address issues of professional bias in terms of including a diagnosis or not.

The arguments against the DSM and psychiatric influence vary across the usual spectrum of there being no such thing as a psychiatric diagnosis to there are too many diagnoses to the fact that psychiatric diagnoses are nonspecific.  There is no practical way to incorporate that spectrum into a diagnostic manual that is designed for psychiatrists to make clinical diagnoses and do research.  The single most important fact that is left out of these debates is that psychiatrists are effective in treating serious mental illness and they are undoubtedly more effective now than they have been in the past.  That is the only reason we need a DSM and that is why it stays squarely in psychiatry.

George Dawson, MD, DFAPA  


Frances A.  Diagnosing the DSM.  New York Times May 11, 2012.

Frances A.  DSM5 begins its belated and necessary retreat.  Health Care Blog May 10, 2012.

Kessler RC, Avenevoli S, Costello J, Green JG, Gruber MJ, McLaughlin KA,

Petukhova M, Sampson NA, Zaslavsky AM, Merikangas KR. Severity of 12-month DSM-IV disorders in the national comorbidity survey replication adolescent supplement

Arch Gen Psychiatry. 2012 Apr;69(4):381-9.

Munk-Jørgensen P, Najarraq Lund M, Bertelsen A. Use of ICD-10 diagnoses in Danish psychiatric hospital-based services in 2001-2007. World Psychiatry. 2010 Oct;9(3):183-4.

Regier D, Kaelber CT.  The Epidemiological Catchment Area Program:  Studying the Prevalence and Incidence of Psychopathology. in  Textbook in Psychiatric Epidemiology eds.  Ming T Tsuang, Mauricio Tohen, and Gwnedolyn EP Zahner.  John Wiley and Sons, 1995. p141.

Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2007. National Center for Health Statistics. Vital Health Stat 13(169). 2011. (see Table 7.)

Radicals and Reformers for Managed Care

I was struck by a post on the Critical Psychiatry blog this AM.  Duncan Double discusses his experience at a meeting of the radical caucus at the APA on Sunday.  His main argument was the need to abolish psychiatric diagnostic systems - specifically the DSM, but he mentions that you can apparently provide psychiatric services without an ICD diagnosis in the UK.  But then he makes this astonishing comment: " The American psychiatric system has become very dependent on DSM for billing purposes, but I'm sure the insurance companies could develop an alternative system unrelated to DSM. "


I am positive that the American insurance industry would like nothing better than to establish their own "alternative system unrelated to the DSM'.  In fact, they are doing it already with a host of measures that they can use to basically deny care or dismantle systems of care.  The managed care industry in the US has selectively discriminated against psychiatric services for the past 20 years to the point that most states have little service availability.  The motivation for managed care is clear - shift hundreds of billions of dollars away from providing care to persons with mental health and chemical dependency problems and into the pockets of the insurance industry.  We are talking about an industry where the CEOs can make an annual salary of millions of dollars and in a famous case the CEO received a $1 billion dollar bonus.


Stated in another way, the "American psychiatric system" is no system at all.  There is hardly any availability of psychotherapy services.  Most people are restricted to a handful or less of 15 minute visits with a psychiatrist every year.  The length of stay in hospitals is appallingly short by UK or European standards and people are asked to leave if they are no longer "suicidal".  It is psychiatrists on the one hand being severely restricted in attempting to provide care and a predatory insurance industry trying to make disproportionately more money off policy holders with mental health problems on the other.   The government is not a passive player in this effort with most state governments abdicating their role in caring for the indigent and the uninsured often by using managed care tactics.  All of this happens independent of any DSM or ICD diagnosis.  At the national level, there is a long list of interests who favor the same tactics in order to maintain leverage over doctors and the clinical care advocated by doctors.


Critical psychiatry would rather "Occupy American Psychiatric Association" rather than "Occupy Wall Street" .    I guess we can add them to the managed care  list.  That is exactly the type of reform that the politicians want.