10 Stories on DSM-V

Ken Pope’s listserv has been positively percolating with stories on the revision of DSM-V. It would be a full time job keeping up with the various controversies, but this list provides a bird’s-eye view of the range of concerns. The committee overseeing the revision of DSM-V is taking feedback up until this Friday, June 15, 2012:

1.   Revised Criteria For Mild Cognitive Impairment May Compromise the Diagnosis of Alzheimer Disease Dementia. Article at the Archives of Neurology.

Briefly quoted: “The original diagnosis of MCI6 – 7 was limited to individuals with cognitive impairment in a single domain (memory), thus distinguishing MCI from dementia, but more recently its differentiation from dementia has come to rest solely on the preservation of functional activities.8 – 9 The revised criteria for MCI,2 however, allow considerable latitude as to what represents functional independence and thus blur the categorical distinction between MCI and dementia.”

2.   Researchers Voice Concern Over Proposed Addiction Guideline Changes. From a press release at the University of Connecticut.

Briefly quoted: “Psychiatric epidemiologist Thomas F. Babor, head of the Department of Community Medicine and regional editor of the international journal Addiction, and Dr. Yifrah Kaminer, professor of psychiatry and pediatrics in the Department of Psychiatry and Alcohol Research Center, are concerned that pending changes to the definition of addiction in the Diagnostic and Statistical Manual (DSM) could represent a step backward in diagnosing and treating substance use disorders – and could have major economic and social consequences…. Babor’s reservations about the proposed changes concern the broadening of language defining addiction and the lowering of the threshold of what counts as a substance use disorder. The revisions would expand the number of symptoms of addiction, reduce the number required for a diagnosis and introduce a “behavioral addiction” category – all of which could lead to millions more people being categorized as addicts when they in fact are simply unhealthy users. This could put a strain on already-limited resources in schools, prisons and hospitals, he says.”

3.   A Closer Look at Pending Changes to the Future of Psychiatric Diagnosis. From a news release at the Journal of Nervous and Mental Disease. The special section notes several articles regarding proposed DSM changes.

Briefly quoted: “Many articles within the section present criticisms of DSM-5 proposals. Specifically, several authors worry that the new DSM-5 standards may open up more opportunities for false-positives – a doctor diagnosing a condition when it is not present, or providing medication when it is not needed.” 

Subsection titles include: “Behavioral Addiction V Quo Vadis”, “Hebephilia and the Construction of a Fictitious Diagnosis”, “Should Prolonged Grief Be Reclassified as a Mental Disorder in DSM-5? Reconsidering the Empirical and Conceptual Arguments for Complicated Grief Disorder”,  “Psychotropic Marketing Practices and Problems: Implication for DSM-5”, and “A Critique of the DSM-5 Field Trials.”

4.   Premenstrual Dysphoric Disorder: Why it Doesn’t Belong in DSM-5. Available as a brief podcast.

5.   International Dyslexia Association Requests Reinstatement of the Term “Dyslexia” in American Psychiatric Association’s DSM-5. A news release from the International Dyslexia Association.

Briefly quoted: “However, many view this latest round of revisions — which now omits the term dyslexia — as a significant step backward and worry that this omission will perpetuate lack of recognition and understanding of dyslexia and contribute to delays in diagnosis and treatment.”

6.   Changes to Name, Definition of Mental Retardation Raise Concerns. An article at Education Week.

In the case of the definition of mental retardation, the American Association on Intellectual and Developmental Disabilities said that plans to change mental retardation to “intellectual development disorder” doesn’t match shifts in the United States and abroad to use the term “intellectual disability.

7.   The psychiatric oligarchs who medicalise normality. From a letter to the editor at the British Medical Journal, responding to the article of that title.

8.   Tradition versus empiricism in the current DSM-5 proposal for revising the classification of personality disorders. From an editorial at Criminal Behaviour and Mental Health.

From the abstract: “The DSM-5 proposal is for a confusing, complex and inconsistent system that lacks credibility. A broad overview of the study of personality disorders suggests that the field is having difficulty integrating traditional concepts and modes of practice with empirical findings. The basic theoretical models and concepts underpinning contemporary ideas about classification, aetiology and treatment are largely based on clinical observations. Although these observations often yielded remarkable insights, they were relatively unsystematic and based on small, unrepresentative samples. Evidence and methods are available to construct an innovative and empirically informed classification with high clinical utility that could advance our understanding of the nature and origins of personality disorder. But to implement such a system, one needs the courage and ability both to move beyond traditional assumptions and presuppositions and to ignore political considerations.”

9.   The American Family Therapy Academy released a policy statement about DSM-5. AFTA finds APA non-responsive to feedback.

“AFTA has joined over fifty organizations and thousands of practitioners and researchers worldwide, in writing to the DSM Task Force and the American Psychiatric Association to express these concerns. The response from the American Psychiatric Association has been minimal, at best. None of the organizations or individuals have been invited to participate in the decision making process. We find that the current revision of the DSM continues a long history of ignoring research and excluding vital contributions of non-psychiatric mental health disciplines resulting in invalid diagnostic categories and treatment protocols.”

10.  Criticism Continues to Dog Psychiatric Manual as Deadline Approaches by Greg Miller at the Journal Science. 

“When planning for DSM-5 first began in 1999, its leaders hoped to tap advances in neuroscience and genetics to create a taxonomy of mental illness that better carved nature at its joints (Science, 31 October 2003, p. 808). That didn’t happen to the extent they had hoped. We could not construct a diagnostic classification on the basis of neuroscience findings at this point,” acknowledges David Kupfer, a psychiatrist at the University of Pittsburgh School of Medicine in Pennsylvania and the chair of the DSM-5 committee overseeing the revisions.”

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FDA and Child Bipolar

Philip over at Furious Seasons is on a rant about the FDA legitimizing the childhood bipolar diagnosis, one which does not yet occur in the DSM. Essentially, it sounds like the rationale is that since they’ve approved studies about medicating the disorder and approved dosages of Abilify and Risperdal with children — then the disorder exists. Today Furious Seasons posts all about the adverse effects of those two drugs. The excerpt from yesterday’s post:

Earlier today, I asked the FDA to respond to a statement made by Harvard child psychiatrist Janet Wozniak, wherein the doctor claimed that the FDA accepted the validity of the hotly-debated child bipolar disorder. That was news to me, since the diagnosis does not exist in the DSM and many child psychiatrists such as Jack McClellan and Larry Diller, both affiliated with major medical schools, even claim that the child bipolar diagnosis is not real.

Addendum: Clinical Psychology and Psychiatry also posts on this topic, and points to a John Grohol post at Psych Central, also on child bipolar. Dr. Grohol rightly points out that the FDA logic for sanctioning this diagnosis is circular…

From The Candid Psychiatrist

The Candid Psychiatrist: Giving Contemporary Psychiatry the Spanking it Deserves. That’s the full title of the Candid Psychiatrist a blog by Dr. Paul Minot.

The author of the blog describes his “best post”: “The ‘Chemical Imbalance’: A Convenient Truth”

Here’s how the essay begins:

You have a chemical imbalance. Millions of people have been persuaded to take antidepressant medication by this simple phrase. Depression, an illness long associated with connotations of weakness and feelings of shame, is recast as a physical malady of abnormal chemistry-which naturally calls for medication by a doctor. How can a patient feel in any way responsible for a chemical imbalance? Why would any reasonable person refuse treatment for such a condition?

One good reason to do so is because no such chemical imbalance has yet been proven to exist. It can’t be identified by blood test or any other objective examination in patients with depression; nor has it been definitively confirmed in postmortem examinations, animal studies, or any other reliable research. Although it is purported to be the most scientific explanation we have for depression, it is not established scientific fact. Nonetheless, over the past two decades this clinical mantra has become an article of faith for psychiatrists, patients, managed care companies, and a multibillion dollar pharmaceutical industry. It is a singular example of a knowledgeable community falling for its own line of bullshit.

Those who have challenged this biological model of depression have typically laid the lion’s share of blame on Big Pharma, which has had the greatest role in bankrolling this myth and profiting from it. However, deeper examination reveals that the ascendancy of this theory has been driven by other factors as well, including the inherent inadequacies of psychiatric diagnosis, and the “quick fix” fantasies of managed care companies and psychiatric patients alike. On another level, faith in the chemical imbalance can be seen as the latest flawed answer to psychiatry’s longstanding collective prayer for deliverance from the grave insecurities that have plagued this medical specialty since its inception.

Discriminating Among Anxiety Disorders

An automatically generated link led me to a very nice old post at We Worry: A Blog for the Anxious about discriminating between anxiety disorders. Apparently weworry.com received some accolades last year (see the website), so you might want to check it out, particularly if you have questions about anxiety. For instance, If you click back to their homepage there’s another nice post titled, “Feel the Fear.” The post mentioned earlier, titled “What’s in a Diagnosis?” starts like this:

One of the most commonly heard questions on internet anxiety-support forums is some variation of: “Is this Generalized Anxiety or Panic Disorder?” Much discussion revolves around the diagnoses and their symptoms, yet the most important thing you will ever learn about your diagnosis is this: it’s largely irrelevant. Aside from the insurance companies and the FDA’s medication standards, your diagnosis has little bearing on your recovery.

The anxiety disorders fall on a spectrum and there is rarely an individual who shows signs of one without showing signs of another. Many people ultimately diagnosed with Generalized Anxiety Disorder (GAD) typically show signs of Obsessive-Compulsive Disorder (OCD). For example, many GADers experience chronic, nagging fears about their health (mental or physical); this is sometimes referred to as hypochondriasis or “health anxiety.” You may not realize it, but your constant thinking and analyzing of physical or mental symptoms is actually a ritual. So is your constant need for reassurance. If you find new symptoms and then rigorously search for relief from Dr. Google, then you’re performing a ritual. We often know this ritual won’t help much, but we can’t help it, we just have to know about the disease we fear so much.

Check out the rest of the post here. Again, the site seems like a good place to start if you’re interested in anxiety.

DSM linked to Drug Companies

No surprises here. The Diagnostic Statistical Manual (DSM) used to diagnose “mental illness” is linked to the psychopharm industry. From the New York Times, here:

More than half of the task force members who will oversee the next edition of the American Psychiatric Association’s most important diagnostic handbook have ties to the drug industry, reports a consumer watchdog group.

It’s not the first time the D.S.M. has been linked to the drug industry. Tufts University researchers in 2006 reported that 95 — or 56 percent — of 170 experts who worked on the 1994 edition of the manual had at least one monetary relationship with a drug maker in the years from 1989 to 2004. The percentage was higher — 100 percent in some cases — for experts who worked on sections of the manual devoted to severe mental illnesses, like schizophrenia, the study found. (For a Times story on that report, click here.)

Loss of Sadness

A piece at Business Day (Zimbabwe) makes some nice points about depression. The referrence The Loss of Sadness by two sociologists, Allan Horowitz and Jerome Wakefield. The article is written in the context of recent findings that SSRIs may be no better than placebo, that in some places access to talk therapy is limited, and that, finally, it appears that antidepressants (SSRIs) may be being overprescribed.

1. There’s no blood test for depression (yet it exists).

Depression is not an illness that has a blood test to exclude or diagnose it. Rather, it is a diagnosis reached by observation, talking, and sometimes also by questionnaire, using criteria set out by the Diagnostic and Statistical Manual (DSM).

2. Some symptoms of depression.

A depressed person may suffer loss of appetite or loss of the ability to feel pleasure, early-morning wakening, a feeling of hopelessness, fatigue, and often a feeling that life is not worth living. The number and intensity of these feelings results in categorisation of the disorder into mild, moderate or severe.

3. Sad feelings in response to day-to-day challenges — not necessarily depression.

But not all such feelings are necessarily abnormal. After bereavement, or a relationship breakdown, it is normal to have a disturbance of mood. However, the criteria used to diagnose depression do not take account of the context of the life in which they occur. The DSM criteria suggest that symptoms of depression lasting over two weeks merits a diagnosis. This means that an understandable and proportionate response to a significant loss in a person’s life is instead viewed as an abnormality, and the patient is diagnosed as depressed.

And by extension, they are prescribed antidepressants, for problems of living. This may temporarily remove a symptom, but it is covering over a conflict that needs to be addressed. Examining these sorts of conflicts in talk therapy — this is where psychotherapy really does good work.

Kalea Chapman, Psy.D.

Is that Schizophrenia or a Schizophrenic?

The all powerful receptor. Harold Maio quotes one participant’s part of the New York Times Freakonomics piece on the progress of psychology and psychiatry:

“It works by binding to certain receptors in the brain, and if you give it to “schizophrenics,” many of them stop their otherwise full-blown hallucinations.” Until the practice of referencing people as diseases ends, psychiatry will continue to fail. “schizophrenics,” indeed!!

Schizophrenia or schizophrenic — what’s the difference?
The source of Maio’s indignation might be lost on some. What he is sorely rejecting to is the objectification of the patient. Rather than “schizophrenic,” I am quite sure he would prefer “the patient suffering from schizophrenia.” What’s the big difference? The former, schizophrenic, implies an outcome, foreclosure, even worse — an identity.

The latter implies a process, with a number of symptoms that come and go, it also implies that there’s a person in there! No doubt — schizophrenia is a lifelong condition that requires medication, management, and psychotherapy, but to be a “schizophrenic” sounds like a life sentence rather than a lifelong condition. Please take a look at Elyn Saks’ book on this topic. (She manages to graduate from Oxford and teaches law at USC, all while having a diagnosis of schizophrenia.)

The objectification reminds me of a New Yorker story about medical training. At a certain point in his training the writer recounted that he and his colleagues starting referring to the body parts of the people they were treating, rather than the people themselves. “You should see the liver in room 18!”

As clinicians we can never lose sight of the fact that we are treating human beings with human problems, and there is not so much separating them from ourselves.

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Kalea Chapman, Psy.D.