Tuesday, July 7, 2009

The DSM-V Armageddon, Part 2

Dr. Jane Costello has had enough of DSM-V, and has quit the prestigious DSM-V Work Group on Disorders in Childhood and Adolescence. Her letter of resignation has been making the rounds (with her permission); I've reproduced it below, or you can access it directly here. Dr. Costello is a full Professor at the Duke Institute for Brain Sciences where she co-directs the Center for Developmental Epidemiology, and she is an international expert in understanding the course of mental illness across the life span.

Essentially, Dr. Costello resigned because she feels that the DSM-V process is being rushed to completion without an adequate scientific basis:

"When we began this process [she is referring to the DSM-V work group], we agreed that changes would only be made if there were empirical evidence to support them. Sometimes (as with Charlie’s work on preschool PTSD) this has been the case. But as time has gone by, the gap between what we need to know in order to make revisions and what we do know has grown wider and wider, while the time to fill these gaps is shrinking rapidly. More and more, changes seem to be made for reasons that have little basis in new scientific findings or organized clinical or epidemiological studies."

I encourage you to read her entire letter--it's a fascinating glimpse into the sausage-making process which is how a profession's bible gets constructed.

But wait! There's more!

Dr. Robert Spitzer has sent around this
letter written by both himself and Allen Frances to the APA Board of Trustees in which they call for the appointment of a "DSM-V quality control committee" to oversee what they view as a broken process. Their letter recaps some of the same arguments Frances made in this his soon-to-be-published editorial (which I covered in this post) while adding five specific steps that need to be taken.

As William Butler Yeats wrote in his poem The Second Coming, "Things fall apart; the centre cannot hold... " The Fifth Coming of DSM threatens to rend the fabric of American psychiatry. Let's hope some cool heads in the APA's leadership can find a way out of this mess.

Jane Costello Resignation Letter from DSM-V Work Group to Daniel Pine March 27, 2009


Anonymous said...

It is a shame that uncertainty about diagnosis and treatment cannot be met with acceptance rather than an unwielding desire to control. Starting from a place of unknowing can lead to a valid discovery process. Setting up false timelines and demands for clarrification of unclear things subordinates the discovery process. This is a tragic case of misplaced emphasis.

skillsnotpills said...

Maybe I am on to something here. Thank you for emailing me about your post, not that I wouldn't have read it by the end of the day anyway, but I appreciate your noting my interest in this issue.

This is the final nail in the coffin of our profession, doctors. I have been saying this for months, and I feel basically just blown off or minimized thus far. Just wait for the henchmen (and women) to come and project their bs onto you and your colleagues who give a damn and are correct in challenging this DSM V project that is Goldman-Sachs in intention.

Don't be nice and polite with the crowd forcing this crap on us. It is evil, plain and simple. Hence the above post noting why this responsible colleague resigned.

Kudos to her and all who reject Dr Schatzberg and his ilk!

Sara said...

IMHO psychiatry needs to let go of diagnosis as the holy grail to treatment. Treatments in psychiatry are completely divorced from the root causes of someone's symptoms (despite assertions of the existence of "chemical imbalances") and are simply temporary palliatives to tranquilize or stimulate. Far too much emphasis is placed on the DSM which really is only good for a certain predictive power in recognizing groups of symptoms that seem to congregate together. The real work of psychiatry should be in helping patients reframe the traumas and stress that led them to exhibit symptoms in the first place. No DSM is going to help with this. Of course this is very idealistic on my part but it seems to be a task that is now being generally overlooked in the effort to define ever bigger and better "disorders." For what purpose, I ask, since the same meds are literally being used for all the disorders. It's not like there is going to be some radical refinement of treatment by "perfecting" what truly are very arbitrary diagnoses. It's not like psychiatrists are going to let go of what even they claim is "more art than science" in the treatment of mental illness.

With apologies to the professionals here. I know this probably comes across rather harshly but I have seen as much, if not more, harm from diagnosis as from treatment. And treatment hardly seems to be very disorder specific as it stands at the moment. It all seems like a grand waste of time and somehow a self serving effort by psychiatry to appear more like other branches of medicine that do have diseases that can be objectively determined by science and biology. Psychiatry shouldn't need to apologize for not being like other medical specialties. It is something different and it should accept that it is. Helping people understand their lives and their stories is important work.

Dark Jay said...

I am a firm believer in diagnostic accuracy. While Sarah raises a valid point about the generality of pharmacotherapies I feel this has much more to do with the pursuits of drug manufacturers, who have devoted considerably more effort/resources to refinements of existing agents than the development of "novel" agents. There is clearly a need for a revision of the DSM. I work in the CMH system and our psychiatrists are assigning ever more NOS diagnoses than I've encountered in 24 years of practice. The criticisms of Drs. Frances and Spitzer are right on the mark. And I am saddened by Dr. Costello's resignation.

These events expose the many fractures within psychiatry and psychology. We truly are much like the blind men groping an elephant, each trying to identify it from a limited vantage. At this point we are missing the bigger picture and our professions will only be limited and further marginalized by the current course of this conflict. Right about now we're smelling pretty rank.

Sara said...

Unfortunately I do not really believe in "diagnostic accuracy" in psychiatry because each person has a unique story, unique traumas, unique stressors, and unique ways of coping (or not, as the case may be). That doesn't mean there aren't certain patterns and it may be useful to understand those. Also once treatment has started diagnostic accuracy really falls by the wayside because medications confound and confuse the trajectory of symptoms so that what's unique to the person and what's due to adverse reactions are impossible to differentiate (or maybe not -- it's often mostly adverse effects). Please explain to me what the value of diagnostic accuracy really is to a particular patient, especially once medications with profound neuropsychiatric effects are in the picture. I'd like to know. And if a person is diagnosed, can they ever be "undiagnosed?" Is there any acknowledgement in psychiatry that people can get better and live med free again? You're talking to someone who took her young adult daughter to the emergency room (at Stanford) and was told after fifteen minutes she would be "medicated for life." I consider this an outrage (and did at the time as well although it was very frightening). I believe this cavalier attitude towards her diagnosis/prognosis was something that led to her death. Was there any meaningful discussion of why she was in crisis or what could be done about it? No, just a checklist of symptoms and attempt to impose a lifelong diagnosis.

If I thought my story was really unusual I wouldn't be posting comments here on this blog that I'm sure is probably read mainly by professionals (and I'm really not trying to second guess you all) but from my experience since that time it appears to be happening over and over again. It's unlikely to get better if the DSM-V goes ahead as planned.

Gina Pera said...

....pursuits of drug manufacturers, who have devoted considerably more effort/resources to refinements of existing agents than the development of "novel" agents...."

This is such a common complaint from people who typically have no idea what is involved in the discovery of "novel" agents and who also have no idea how vital has been the refinement of existing agents and, more importantly, their delivery systems.

Gina Pera said...

Sorry to hear your story, Sara. But no one has ever confused Stanford with great psychiatry. In fact, many people find it best avoided.

Sara said...

"No one" has ever confused Stanford with great psychiatry? Interesting then that their chair would become the head of the APA. But thanks, Gina. I appreciate the insight. It helps a lot.

Anonymous said...

Have you seen the Counterpunch article on this matter?

Anonymous said...

To understand how corrupt psychiatry and the drug industry are -
Alliance for Human Research Protection