Making the Making of DSM-V Transparent

Passing on some information on efforts to make transparent the production of the next Diagnostic and Statistical Manual (or DSM). As you may know, the last two editions were roundly criticized as being arbitrary in their designation of symptoms. Investigation suggests that outside interests, including but not limited to drug companies, contributed to the arbitrariness of symptoms. (see the November 17 post)

UPDATE ON MAKING DSM-V TRANSPARENT

Robert L. Spitzer, M.D.
Professor of Psychiatry, Columbia University
Former Chair of Work Group to Develop DSM-III and DSM-III-R

I want to provide an update on efforts to make the DSM-V revision process sufficiently transparent to serve the purposes of the scientific community. By transparent, I mean that shortly after DSM-V revision meetings or conference calls it should be possible for anyone to find out what happened at these meetings.  APA’s stance should be complete openness with exceptions being made only in those rare cases where release of the information would be problematic (e.g., a discussion about a particular workgroup member’s performance).  Allowing this type of transparency would facilitate outside critiques and recommendations that could improve the quality and scientific integrity of the DSM-V.

As those of you who have followed this issue know, APA leadership has been resistant to improving the transparency of the revision process. At the outset, all DSM-V Task Force and Workgroup members were required to sign a confidentiality agreement that prohibited them from discussing anything about the DSM-V revision process — except in those situations in which the participant judged that sharing such information would benefit the DSM-V process.   Repeated requests to APA leadership to see minutes of Task Force and Workgroup meetings were refused on the grounds that releasing minutes would compromise the revision process by inhibiting free discussions among Workgroup members. It also was argued that making minutes of meetings and conference calls would jeopardize APA’s intellectual property rights. How this would happen has never been explained. DSM-V leadership claimed that their plan to make information about the DSM-V revision process available during presentations at professional meetings and APA in-house publications and peer reviewed journals would be sufficient.

         Pressure on APA leadership to increase transparency culminated in the drafting of an Action Paper by some members of the APA Assembly.  The paper called for the posting of the minutes to the DSM-V workgroup and task force meetings on the DSM-V web site.  (The Assembly is a body within the APA consisting of members who are elected by local chapters to represent the interests of APA membership, somewhat analogous to the US House of Representatives except that they lack legislative power).   In an apparent effort to make it seem that the action paper was not necessaryDSM-V leadership said they would begin posting information about the revision process on the DSM-V web site.  Specifically, they agreed to post reports that are prepared quarterly for the APA’s Board of Trustees, the political body within APA that has direct oversight of the revision process.   Here is a link to the only report posted so far which was prepared for the September 15, 2008 Board of Trustees meeting.  (http://www.psych.org/MainMenu/Research/ DSMIV/DSMV/DSMRevisionActivities/TaskForceReports.aspx ) In addition, each of the 13 Workgroups have been asked to prepare a report every 4 months summarizing their progress.  Reports of the 13 Workgroups that were posted on the DSM-V web site in the week prior to the Assembly vote are available through this link. (http://www.psych.org/MainMenu/Research/DSMIV/DSMV/SMRevisionActivities/DSMVWorkGroupReports_1.aspx ).

         Although clearly a move in the right direction, I believe thatthese reports fall far short of providing the requisite transparency. The Workgroup reports are quite variable in terms of the amount of detail they provide regarding possible directions for change in the DSM-V.  Some are quite detailed (e.g., Eating Disorders) and provide a good window into the process.  Others, like the summary for Anxiety Disorders, is so general as to provide almost no information about problematic issues that the workgroup has identified.  For example, although there has been considerable criticism of the criteria for PTSD (including a special issue of the Journal of Anxiety Disorders devotedto that topic), there is no information provided about possible directions for change–simply that PTSD is one of the subjects of the literature review.   (Given their variability, it is clear these reports were written without guidance as to what and how much information should be included).

         Full transparency of the process will only be satisfied by posting the minutes of all DSM-V conference calls and meetings so that the process of the deliberations is evident to all. Anything less is an invitation to critics of psychiatric diagnosis to raise questions aboutthe scientific credibility of DSM-V. That is exactly what Christopher Lane, a harsh critic of the DSMs, did in an Op-Ed piece for the LA Times.  Here’s the link to Lane’s piece which appeared on Sunday, November 16: http://www.latimes.com/news/opinion/commentary/la-oe-lane16-2008nov16,0,5678764.story

         One of the oft-repeated DSM-V talking points is that the process is “open and transparent.”  To be truly transparent, the nuts and bolts of the DSM-V process needs to be open for outside scrutiny. When it comes to the crucial issue of transparency, even the appearance of impropriety must be avoided. Rather than appearing open and transparent, current APA policy continues to give the appearance that APA has something to hide about how it is developing DSM-V. It remains likely that unwanted media attention will fall on the DSM process until full transparency is achieved.

Recession and Sense of Self

Self doubt. Diminished sense of self. Fear and diminished expectations. Depression. Anxiety. Lack of sleep. These are some of the symptoms being predicted as a result of the upcoming (if not arrived) recession. Washington and Lee University (quote from Shrink Wrap) warn of the following:

What’s really interesting is that this compromised sense of self becomes hardens and is better described as a permanent scar rather than a blemish. Even when people become employed again, the adverse impact of unemployment on psychological well-being lingers.

At the New York Times, David Brooks takes a broader sociological view, but comes to some of the same conclusions. He notes a cynicism from the 70s that never really went away. He notes:

Recessions breed pessimism. That’s why birthrates tend to drop and suicide rates tend to rise.

or

But recessions are about more than material deprivation. They’re also about fear and diminished expectations. The cultural consequences of recessions are rarely uplifting.

 

 

DSM-V and Some New Diagnoses

Just a little piece on the DSM-V update at the Los Angeles Times. Written by Christopher Lane, author of the fascinating Shyness: How Normal Behavior Became a Sickness. Lane has done extensive research into the processes involved in the creation of the DSM. Many of them were quite arbitrary. Here’s a quote from the Times article:

Not only do mental health professionals use it routinely when treating patients, but the DSM is also a bible of sorts for insurance companies deciding what disorders to cover, as well as for clinicians, courts, prisons, pharmaceutical companies and agencies that regulate drugs. Because large numbers of countries, including the United States, treat the DSM as gospel, it’s no exaggeration to say that minor changes and additions have powerful ripple effects on mental health diagnoses around the world.

Behind the dispute about transparency is the question of whether the vague, open-ended terms being discussed even come close to describing real psychiatric disorders. To large numbers of experts, apathy, compulsive shopping and parental alienation are symptoms of psychological conflict rather than full-scale mental illnesses in their own right. Also, because so many participants in the process of defining new disorders have ties to pharmaceutical companies, some critics argue that the addition of new disorders to the manual is little more than a pretext for prescribing profitable drugs.

Prescription Privileges and Standard of Care

It sometimes appears that there’s nothing left to say on this topic — yet there’s occasionally a new wrinkle.

One issue that comes up is whether having a client go for a medication consult is what’s called “standard of care”. Essentially, “standard of care” means that there is some consensus within the profession that minimally competent practice would include the action, in this case a medication consult. In other words, you’d better follow this procedure or open oneself to vulnerability to lawsuits.

Who determines standard of care? Currently when someone comes to us with major depression we are supposed to refer them to a psychiatrist. But how about these scenario? A woman is filled with anxiety due to financial troubles. Is the standard of care to refer to a financial advisor? A man comes with deep concerns about his religion. Is the standard of care to refer to a priest? Are we committing malpractice by exploring such questions without referring?

As usual, it depends. Psychologists, when working as psychotherapists, are duty bound to explore the psychological implications of their clients concerns, first and foremost. It may be that concurrently — or after such concerns are thoroughly explored — a psychologist should consider referring to somone with another specialty, be that a psychiatrist, member of the clergy, or financial counselor.

Psychologists are not giving up their area of expertise by occasionally referring out. Good clinical work often involves consulting other professionals, and always includes knowing the boundaries of one’s competence. On the other hand, referring out in a knee-jerk fashion probably is not good clinical judgment and may even speak to some laziness on a clinician’s part.

Kalea Chapman, Psy.D.

Changing Landscape of Infidelity

The New York Times ran an interesting article on marital infidelity recently. One of the openers is that of women polled face-to-face one percent admitted to infidelity. On a computer questionnaire the number was up to 6 percent.

It’s hard, on the verge of an election that has been heavily polled, not to wonder if similar dynamics are at play. Are people really willing to report what they’re doing (or about to do).

The article notes that infidelity among men is probably related more to social pressures and situational factors than inherent differences in sex drive. A related finding, not in the article, contradicts that finding: Among couples male homosexuals have the greatest amount of sexual intercourse. Heterosexual couples follow that. And lesbian couples have intercourse less frequently. Of course, it’s just research — your mileage may vary.