Thursday, February 11, 2010

DSM-5's Rough Draft: The Carlat Take

In a prior post, I observed that the process of hammering out the DSM-5 had degenerated into a bar room brawl. Major figures in the development of past DSM versions, such as Allen Frances (the DSM-4 chairman) and Robert Spitzer (DSM-3 chairman), had both severely criticized the DSM-V process for lack of transparency and for a headlong rush to get the thing done too quickly in order to start making the APA some money.

Looking at the just-released proposed DSM-5 criteria, I'm pleased to say that the APA leadership has apparently been listening. They've pushed the planned publication out two full years to 2013, giving everybody time to review the proposal and to do some field testing. They have made the process far more transparent by posting task force reports on the DSM-5 web site. And they have avoided trying to pretend that DSM is ready for a paradigm shift in which diagnoses are based on neurobiological criteria (here's a secret--they don't exist yet in psychiatry).

Here's a quick Carlat-tour through some of the the main proposals.

--Temper dysregulation with dysphoria (TDD). A much more accurate way of categorizing children with explosive temper tantrums so that they don't get misdiagnosed as having bipolar disorder. This is a response to the fact that the diagnosis of bipolar disorder in children has increased 8,000% over the past decade.

--Addiction and Related Disorders. No more having to deal with the confusing terms "substance abuse" vs. "substance dependence"--both will be jettisoned in favor of the catch-all term "addiction." Currently, "dependence" is supposed to be a more severe problem than "abuse" but there was no good way of distinguishing the two in real patients. When someone has a problem with drug or alcohol craving, it's an addiction, pure and simple, and DSM-5 will acknowledge this.

--Autism Spectrum Disorders. This makes a lot of sense. No longer do we have to figure out: "Is this mild autism? Or is it severe Asperger's?" Now we can describe such patients as being somewhere on the spectrum of autism and spend more time understanding them as people rather than coming up with just the right label.

--Binge Eating Disorder. Some might see this as a form of disease mongering--that is, expanding the definitions of diseases to label more and more people as mentally impaired. But in fact I see patients with BED (as it's abbreviated) in my office with some frequency. These are not just overeaters, but rather patients who compulsively binge and have lost all sense of control.

--Risk Syndrome for Psychosis. This is a bit more iffy a proposal in my opinion. The idea is that you can diagnose people who have milder symptoms of psychosis before they develop full blown schizophrenia. Then, maybe you can prevent a more severe disease by starting them on prophylactic antipsychotics. But the research is debatable. Only about 35% of patients who qualify for this "pre-psychosis" end up developing true psychosis. I doubt this will make it into the final DSM-5 as an official disorder.

There are others potential disorders to examine, but I'll look at those in future posts. We all have a few years to comment on these proposals, and I think they are offered in the spirit of healthy conversation and debate. Thumbs up to the DSM Task Force.


SteveM said...

FYI: Here is Dr. Allen Frances' opinion of the current DSM V draft.

S said...

A reasonable, experienced, compassionate doctor will not be bound up by DSM diagnoses. So, for example, i doubt that the fate of BED in DSM V will affect the way you treat patients with BED, though its inclusion in the DSM may enable you to more accurately bill insurance or describe the problem to your colleagues. (Please do correct me if i'm wrong.)

But i suspect all of us here know that there are plenty of doctors who can't see past rigid categorization or have a two-dimensional view of their patients. Those are the ones susceptible to generalizing something like BED to include run-of-the-mill overeaters, and the ones who have been misdiagnosing troubled kids with pediatric bipolar disorder. It's not possible to create a DSM perfect enough to force these doctors into reasonable and accurate diagnosis. The problem with psychiatric diagnosis these days goes way beyond the categories we use, and that's my frustration with this debate.

Peter said...

I like the dimensional aspects of the DSM-V,
but, to me, the new set of "disorders" and the criterias for
meeting them, will serve as an even bigger seed that Big Pharma + the APA + the FDA will use to increase further the insanely
vast quantities
of psych meds that are prescribed.
Peter Huang, MD

Anonymous said...

This is about as meaningful as a new version of the bible being printed and it is produced exactly the same way. A bunch of high priests have sat around and decided what the favorable interpretation of the sacred text is. It is revised based on politics and demands from the masses to a small degree but essentially rests on the same ground. Revealed truth. Just because you may agree with some of the changes makes it no more or less valid because none of them are grounded in anything other than the way a group of mostly middle aged white men want to legitimize what they do and how they wish to see the world. They could have stopped with DSM 1. This is longer but there is no more real knowledge behind it than the first one.Psychiatry is the intellectual joke it deserves to be.

Joseph Arpaia, MD said...

Sorry, I disagree that these changes are going to improve the health of the population. Agree much more with Dr. Frances' comments.

One major issue in psychiatry is that the DSM minimizes the effect of the environment on the disorder. See "Stress, the Brain, and Depression" by van Praag, for a more thorough discussion of this.

The minimizing of the environmental effects means that the brain's attempts to adapt to the environment are see as inherent brain pathology. This is as absurd as stating that an immune response to a bacterial invasion is an inherent immune pathology.

By ignoring the environmental factors the psychiatric profession gives itself complete job security by diagnosing life as a mental illness. The only people who will not qualify for a disorder are those who are dead.

S said...

Here's my question for the professionals here: Does the existence of a DSM diagnosis in any way guide or perhaps help to narrow the focus of research?

Also, does insurance give preferential coverage to treatment of some diagnoses? For instance, my boyfriend's insurance distinguishes between serious and non-serious mental illness (I have no idea what they mean by that).

I ask because i am not seeing how the fact of having a diagnosis with a code would affect treatment _by a competent professional_. In my mind, if your patient has something that doesn't quite fit into a preexisting category, you'd give 'em a NOS for billing. Would that affect whether their bills get paid? Would you as a professional be looked at with suspicion if you diagnosed too many people with adjustment disorder NOS?

Just a layperson trying to understand how things work. Thanks for your patience!

Joel Hassman, MD said...

In regard to S's above comment/question, I would like to offer my answer. I often start out my diagnostic impression with an NOS diagnosis after completing an evaluation because I am always cautious in over diagnosing people. I would hope my assessment of a general Mood/Thought/Cognitive disorder is on the right track, but I am always disappointed when I hear a patient tell me a prior colleague "knew what I had" after just an evaluation visit, sometimes related to me a visit of less than 1 hour, sometimes just in 30 or less minutes? Come on, peers, do you really think you can accurately assess a person down to a full 5 digit code in even 60 minutes?

If NOS is a valid code for billing as clarified in the DSM, it is not just unfair insurers will not accept it, it is interfering with the clinical care process. If this kind of thinking is extrapolated to medicine, what, some day insurers will not accept a diagnosis for certain types of cancer if not "specific" enough?

I still wait for colleagues to answer this question: how much does the role of possible axis 2 features play into the axis 1 symptomatology in front of you?

Last I checked, doctors, we are asked to fill out axis 1 through 5 when we present a treatment plan. Are these other 4 axis assessments just for show?

Gina Pera said...

Dr. Charles Parker points out, rightly in my opinion, that the new and improved DSM is simply more descriptive labels with no improvements for patient care -- a "map to nowhere."

Gina Pera said...

@S -- wholly concur that "The problem with psychiatric diagnosis these days goes way beyond the categories we use, and that's my frustration with this debate."

Gina Pera said...

DC wrote: "A much more accurate way of categorizing children with explosive temper tantrums so that they don't get misdiagnosed as having bipolar disorder. This is a response to the fact that the diagnosis of bipolar disorder in children has increased 8,000% over the past decade."

If that's really the rationale, that is just nuts. If the evidence exists for the condition, that's the basis for the diagnosis.

If psychiatrists can't differentiate between childhood bi-polar disorder and other conditions, that's a different matter. And, again, we come down to how psychiatrists are educated. No DSM can ever take the place of critical thinking, close observation and questioning, and factoring in physical metabolic issues.

Anonymous said...

I'm going to spell this out for y'all...too many psychiatrists are a Bud short of a six pack. They don't drive their own decisions.

They're the ones who carry "DSM crib-sheets" with them. They're the ones who give you a brochure and pen with your first Vyvanse prescription...and when you check out you notice a Vyvanse notepad, penholder and clock. Coincidence? They're also the ones who give you Seroquel XR because they have a plethora of samples and cute little bags to put them in. Coincidence? Oh yeah...what about the other meds? Concidence?

If the DSM V is more liberal than the DSM IV, I'm scared. The psychiatrists who run around with "DSM crib-sheets" are going to be giving drugs to people who really don't need them. That's unfortunate because the people to whom they'll be prescibing the drugs won't know any better and will voluntarily take them.

The DSM V is calling for the use of atypical antipsychotics far more than is necessary. I take them for schizophrenia. That is a necessary use...behavioral issues in children? That's not necessary. Using stimulants for ahdh/add that doesn't interfere with your life? I don't get it. What other dangerous, unnecessary drugs are going to be prescribed?

Changing the criteria for mental illnesses so it's easier to get a diagnosis? I tried to be blissfully optimistic and assume it's in the patient's best interest, but it's not. I've truly been helped. It's sad that when the DSM V comes out, some people will get screwed.

gewisn said...

Perhaps each DSM workgroup should be required to have at least one non-academic FP physician (to let us know how diagnostic changes will get used and misused in a PCP office) and one admitted skeptic whose job it is to poke holes in every proposed change.

moviedoc said...

You list Wall Street Journal as pharma friendly, but yesterday's article by Edward Shorter would seem to be an exception. Not that I agree with much of what he says about DSM-V or psychopharmacology:

Overall I think DSM-V may be a step in the right direction, but I wonder how many psychiatrists really pay that much attention to the criteria when deciding what to recommend in the way of treatement.

Anonymous said...

If Risk Syndrome for Psychosis ends up in the DSM V, those responsible for putting it there border on evil. The APA couldn't bring itself to purge its DSM revision committees of people with industry ties and now it wants to open up a whole new world of dangerous and extremely expensive drugs to people who aren't even sick and are very likely to stay that way even without psychiatric intervention. Now who is really going to believe that that has nothing to do with a desire to sell more drugs? I'm not.

Anonymous said...

Ordered, centered, stamped
A simple collection of bits of paper
holding a quantity of possibilities,
outcomes, misappropriations, heartbreak
and formulaic shaming.
A construction taken as fact...
A bedrock for uncertain interactions
to keep some safe in their knowing
about places that cannot really be definitively known and which challenge the proper order of things.
I squint to see it...
can't quite make it out...
can't get a clear picture...
It does my head in to seek clarity-
I wonder if it also feels like this for the ones who diagnose?