APA Threatens to Sue "dsm5watch" Website

I just read Bernard Carroll's interesting post on the Health Care Renewal Blog about the latest DSM-5 brouhaha. It appears that the American Psychiatric Association has sent a "cease and desist" letter to a website critical of the DSM-5. The site was called "dsm5watch," but the APA argues that using DSM-5 in the blog title is an infringement of their trademark. The owner of the blog, Suzy Chapman, having no funds to tussle with APA lawyers, simply changed the name of her site to dxrevisionwatch, which, she says, has resulted in much less traffic.

Is the APA simply protecting its ownership of a lucrative franchise, or is it engaging in something more insidious, what Dr. Carroll calls the "SLAPP maneuver," an acronym for "strategic lawsuit against public participation"? I'm guessing that APA would have had little problem with the site if it were cheerleading the DSM-5 process. It all seems rather heavy-handed to me. After all, the New York Times appears to have no problem with the anti-Times site called TimesWatch. In a democratic society, healthy dissent and debate is part of the package. It may be annoying, but that doesn't excuse the bullying tactics that the APA has chosen.

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.

New BBC Program: Rewriting the Psychiatrist's Bible

Several months ago, a BBC producer contacted me to ask if I'd like to be interviewed for a planned radio program examining the DSM and related topics, such as the relationship between the drug industry and the American Psychiatric Association. Being the shameless self-promoter that I am, I assented, and that program is now available on the BBC website.

Aside from listening to me ramble on about things that you've read about in this blog, you'll hear some very thought-provoking interviews of Michael First, the editor of DSM-IV, Lisa Cosgrove, the U Mass professor who published this influential article about the industry ties of members of DSM committees, Peter Tyrer, a professor at Imperial College in London who talks about the validity problems in DSM disorders, David Kupfer, chair of the DSM-V committee who makes a brief appearance, and others.

To listen to the program, click here.

Here is the BBC's description of the program:

Rewriting the Psychiatrist's Bible

Matthew Hill investigates the links between psychiatrists and the pharmaceutical industry. Should there be increased transparency over top psychiatrists' links to the industry? He looks at the influence of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM), produced by the American Psychiatric Association (APA), which has been heavily criticised in the past for a lack of transparency between the panel members and pharmaceutical companies. Matthew also examines the 'Chinese menu' aspect of the DSM's diagnostic criteria and the sheer number of conditions it includes. Matthew investigates whether the APA's transparency policy goes far enough and if we are medicalising real conditions or just traits of human personality.

Broadcast on:
BBC Radio 4, 8:00pm Tuesday 4th August 2009
Duration:
40 minutes
Available until:
8:42pm Tuesday 11th August 2009

DSM-V Transparency: A Case Study

Last month, I wrote a few posts on the ongoing controversy about DSM-V, which is the next version of psychiatry's "bible," the Diagnostic and Statistical Manual. A quick recap: Dr. Allen Frances, the chair of the DSM-IV task force (who was shut out of the the DSM-V task force) wrote a scathing editorial for Psychiatric Times in which he questioned whether there has been sufficient progress in psychiatry to merit significant changes in the manual. The APA responded with a rebuttal, and so on.

Underlying these tiffs is something that must now be regarded by most APA leaders as a mistake: the early decision to require that DSM-V task force members sign a "confidentiality agreement." Drs. Regier and Kupfer maintain that this was merely a kind of "no-compete" clause to prevent task force members from writing and making money off their own versions of DSM. But Dr. Frances said the agreement was part of DSM-V’s “inexplicably closed and secretive process.”

Confidentiality agreement or not, as it turns out, there are glimpses of complete DSM-V transparency here and there. Take a look at this web page from the excellent Schizophrenia Research Forum website. Entitled "Live Discussion: Is the Risk Syndrome for Psychosis Risky Business?", this describes in detail the proposal for a new disorder called "Risk Syndrome for Psychosis." You can access the proposed criteria for the disorder, including the text discussing characteristics, associated features, differential diagnosis, etc.... So far, there are 23 comments posted, constituting a rigorous debate about the pros and cons of the proposal.

At this point, the diagnosis may or may not make it into DSM-V. It really depends on whether there is strong enough research indicating that treatment of early forms of psychosis can head off the later development of schizophrenia. My understanding is that the research is unconvincing, but I'm willing to defer to these specialists, who clearly know a lot more about psychosis than I do.

The point is not so much whether "Risk Syndrome for Psychosis" ends up winning a coveted spot in the DSM-V pantheon; rather, the point is that here is a case study of complete transparency, and it doesn't hurt one bit. In fact, it works exceedingly well, because it lets everyone in on the psychosis work group's thought process and it invites comments on a specific proposal. Where's the beef? It's here.

Unfortunately, if you go over to the DSM-V website and look at the official "Report of the DSM-V Psychotic Disorders Work Group," all you'll find is a very brief summary of some of the topics under discussion. The only mention of the Risk Syndrome for Psychosis is telegraphic: [One issue being considered is] "adding a risk syndrome section to DSM-V and including risk for conversion to psychosis as a category." There isn't even a link to Schizophrenia Research Forum website.

The same level of detail (ie., almost no detail) applies to the other work group reports as well. In their rebuttal to Frances, the APA leadership maintained that "the process for developing DSM-V has been the most open and inclusive ever.” Apparently they were referring to various presentations at conferences. If they want to be credible, I suggest they instruct the chairs of each work group at least to post links to all web pages containing specifics of proposed disorders. That would be true transparency, and it would make a lot of disgruntled psychiatrists happy.

"Old Friends" Battle it out Over DSM-V Psychosis

Yesterday, Psychiatric Times published this response to the Allen Frances critique of DSM-V. It is written by William Carpenter, who is Professor of Psychiatry at the University of Maryland, and the chairman of the DSM-V work group on psychosis.

Carpenter begins his response by saying that Allen Frances is an "old friend," although from the tenor of this article, "old" may be the operative word. I know Dr. Carpenter myself, having interviewed him for the March 2007 issue of The Carlat Psychiatry Report, and having chatted with him here and there at APA meetings. He's a southern gentleman, and I found him very forthcoming and honest about a range of issues, including his refreshing skepticism of the value of some of the newer atypical antipsychotics. He has done some consultation with drug companies but very little over the past few years. He's definitely no hired gun, and he speaks his own mind.

The bottom line is that Dr. Carpenter is extremely credible and anything he says or writes you have take seriously. And if you were to boil down his response to Dr. Frances to a few sentences, it would be:

"In actuality, there will be very few substantive changes in the DSM-V. Most of the diagnostic criteria will be the same. We might add a handful of rating scales. There will be no 'paradigm shift.' We are considering adding a sub-threshold psychosis diagnosis but then again we may not--it's a complex scientific issue and we, like you, are concerned about overdiagnosis and stigma."

Basically, Dr. Carpenter is saying that Dr. Frances has created a sensationalized straw man argument, making all kinds of predictions about DSM-V, few of which will materialize.

Of course, Carpenter is focusing on only one of many diagnostic categories, so the Frances critiques may still apply to the rest of DSM-V. Hopefully, we'll hear from the other Work Group chairs soon.

Psychiatry’s DSM-V Process: Now A Bar Room Brawl

Psychiatry’s diagnostic manual is due for a revision. But what began as a group of top scientists reviewing the research literature has degenerated into a dispute that puts the Hatfield-McCoy feud to shame.

The latest installment in this remarkable episode of American psychiatry involves an editorial by Dr. Allen Frances, the chairman of the committee that created the current version of the the DSM, the DSM-IV. The editorial has not even been officially published (it is in press at Psychiatric Times) but already it has made the rounds of the blogs and is being read and debated widely. Now, the APA has just released this rather stunning response.

Those who are not in psychiatric circles might find their eyes glazing over a bit as they read these articles. But we are witnessing here something dramatic and important. Psychiatry is wrestling with its identity, and in the process is creating the next set of ideas that will guide how real people are diagnosed and treated for years to come. The stakes for everybody are high.

In his editorial, Dr. Frances criticizes the evolving DSM-V on multiple levels, and makes the following claims:

--The process of writing the manual is less transparent and less inclusive than the process he oversaw when he chaired the DSM-IV committee.

--The underlying science of psychiatry has not advanced enough to merit the kind of extreme makeover proposed by the DSM-V chairpeople:

"The simple truth is that descriptive psychiatric diagnosis does not need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even one biological test is ready for inclusion in the criteria sets for DSM-5."

--The main change being proposed—the official inclusion of a series of rating scales into the diagnostic criteria—is poorly conceived because busy clinicians will reject this extra paper-work.

--Other proposed changes in DSM-V will make it too easy to over-diagnose a range of conditions:

“The result would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatment--a bonanza for the pharmaceutical industry but at a huge cost to the new false positive "patients" caught in the excessively wide DSM-V net. They will pay a high price in side effects, dollars, and stigma, not to mentions the unpredictable impact on insurability, disability, and forensics.”

Frances’ article is compelling, not only because of the substance of his arguments but because of his clear and forceful writing style. With each sentence, you get a sense that this man has carefully thought through all of these issues and is passionately concerned about the future of his field.

The APA’s response, on the other hand, is a weird mixture of bureaucratese and mean-spiritedness. The bureaucratese I can understand—after all, this is a letter crafted by committee. But the nasty tone of the response is astonishing and undignified.

The APA gets off to cringing start by calling Frances and his colleagues liars:

“The commentary “A Warning Sign on the Road to DSM-5: Beware of its Unintended Consequences” by Allen Frances, M.D., submitted to Psychiatric Times contains factual errors and assumptions about the development of DSM-V that cannot go unchallenged. Frances now joins a group of individuals, many involved in development of previous editions of DSM, who repeat the same accusations about DSM-V with disregard for the facts.”

Wow. Can’t grown men have disagreements with one another without resorting to this kind of language? I might have started with something more like, “The commentary “A Warning Sign on the Road to DSM-5: Beware of its Unintended Consequences” by Allen Frances, M.D., is a thought-provoking critique of the DSM-5 process. While we respect and appreciate Dr. Frances’ leadership in American psychiatry over the years, we disagree with several of his points.” (Note to APA--send me all future "defense letters" for editing, at no charge).

After this, there are six paragraphs addressing some of Frances’ specific points. We hear that the DSM-V process has actually been “the most open and inclusive ever” and that the much villified “confidentiality agreement” was created to protect intellectual property rather than to keep proceedings secret. There is a defense of the usefulness of symptom rating scales: “Recent studies underscore the readiness of clinicians in both primary care and specialty mental health settings to adopt dimensional instruments on a routine basis.”

And there is a reasonable reminder of why some changes in the criteria are needed: “Clinicians complain that the current DSM-IV system poorly reflects the clinical realities of their patients. Researchers are skeptical that the existing DSM categories represent a valid basis for scientific investigations, and accumulating evidence supports this skepticism.”

But after a brief, not terribly convincing rebuttal of the merits of Frances' argument, the writers decide to conclude by getting mean and personal again. This time, they accuse Dr. Frances of being deceptive in not disclosing his financial interests in DSM-IV (he is co-author of one book that teaches doctors how to use the manual). Then, they opine that Frances’ real motive in criticizing DSM-V is not a desire to improve diagnosis, but simply greed.

“Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing.”

In other words, Dr. Frances wrote his editorial because he was just informed that once DSM-V is published, the APA will no longer publish new editions of books introducing psychiatrists to the outdated DSM-IV. Somehow, I doubt that this was exactly a news flash to Dr. Frances.

It is disturbing that the APA and DSM leadership would accuse Dr. Frances and his colleagues of being greedy, deceptive, and dumb. Who do they think they are--bloggers?