Alert to the Research Community—Be Prepared to Weigh In on DSM-V
Alert to the Research Community—Be Prepared to Weigh In on DSM-V
This commentary suggests how the research community can be instrumental in improving DSM-V and helping it avoid unintended consequences. According to several converging, anonymous (but I think quite reliable) sources to which I have had access, the draft options for DSM-V will finally be posted between mid-January and mid-February 2010. There will then be just 1 month (until mid-March) for collecting comments. The good news is that the products of a previously closed process will finally be available for wide review and correction. The bad news is that there will be only a brief period allotted for this absolutely crucial input from the field.
The research community has a central role and a great responsibility in taking advantage of this precious opportunity to carefully review and identify the problems in the DSM-V drafts and to suggest solutions.
Problems with the DSM-V process
The dangers of the “everything is on the table,”1 ambitious, innovative bias of DSM-V have been amplified by its secrecy and weak methods. There has been a remarkable lack of the free flow of ideas that is necessary to prevent any DSM process from becoming idiosyncratic and arbitrary. Many of the work groups have functioned mostly on their own without sufficient monitoring from the DSM-V Task Force, a large group of diverse advisors, or the field as a whole.
The original DSM-V timeline had the fatal flaws of scheduling field trials before the proposed changes could be vetted by the field and an impossible publication deadline of May 2012. Fortunately, my sources suggest that this plan has been shelved and that a new timeline has field trials following the posting of options as well as a new DSM-V publication date of May 2013.
Unfortunately, there are still numerous problems with the process. There is continued bewildering secrecy concerning timelines and methods. My sources indicate that a grant request for external funding for the DSM-V field trials has been rejected, and there is no indication that there is sufficient money, time, or expertise to conduct meaningful field trials that would measure the impact of changes on the rates of disorders.
The few papers published to date by the DSM-V leadership1-3 (and the wordings of the few work group criteria sets that have surfaced at meetings or informally) display a lack of the one skill that is absolutely essential in crafting an acceptable diagnostic manual—the ability to write clearly and consistently.
It will be no surprise if the draft criteria sets that appear early next year are poorly written and include many worrisome suggestions. This should not be at all blamed on the DSM-V work group members. It is my experience (repeated with DSM-III, DSM-IV-TR, and DSM-IV) that early work group drafts are always, and probably inherently, riddled with serious problems.
Work group members are selected because of their special contribution to research in their own narrow area of expertise. They tend to overvalue their own section and make decisions based on highly selected research and clinical experiences. Thus, work groups routinely have an overconcern about false negatives; an underconcern about false positives; and insufficient concern about how suggestions will eventually play out in the general psychiatric and primary care settings where most people receive their diagnosis. Add to this that work group members lack experience in the difficult art of criteria writing and it is guaranteed that their first products will usually need many months of extensive internal and external review and detailed editing before being ready for field testing.
The iterative polishing and disciplining of work group products must come from an integrated effort that includes contributions from the DSM-V leadership and editorial staff; the task force as a whole; a large and diverse group of advisors; the oversight committee; and finally, and most important, the field at large. The first DSM-V drafts will serve as a starting point for public comment and the painstaking revision process.
Dr. Frances has repeatedly expressed very appropriate concerns regarding the content of the developing DSM-5. I think the more important tort, however, should be with the process. I am a graduate of the Napa State Hospital residency program, closed by decertification of the program by the Residency Review Committee some years ago. The reason our program is no longer extant was that the training was TOO DIVERSE! The plethora of adjunct training sites in the Bay Area created an embarrassment of riches, providing a breadth of experience that other programs could not match. By a similar stretch of logic, the current DSM revision task force, as stated on the DSM website, restricted input to clinicians who were not familiar with the history of the manual. They did this in order to ensure fresh input (see term limits elsewhere). We are now risking the legacy of the finest work in psychiatry from the 20th century, as this potential replacement nosologic manual careens away from the Feighner Criteria and DSM III. We need to stop and reconsider: are we pruning a manual to produce a more naturalistic grouping and naming of the entities we call psychiatric illness, or are we opening a door for relaxed rules of prescribing, as the dimensional assessments seems likely to do?
Dr Mota-Castillo and his colleagues would have few cases--if any-- of ADHD, OD, CD etc., were it not for the widespread consumption of refined seed oils in the USA, since about 1920. Vacuum deodorization of smelly cottonseed and peanut oils was invented in Savannah, Georgia, in 1899, by food oil chemist David Wesson. These oils are low in vitamin E, which results in cerebral lipid peroxidation (eg. ADHD kids exhale ethane gas, a marker of such peroxidation: B Ross, 2003). Prenatal exposure results in a typical ADHD kid, plus a forgetful, photophobic mother, who takes sunglasses everywhere she goes. The same oils cause Alzheimer's in later life. Any ADHD kid still exposed to these common salad and frying oils in their daily diet will be exhaling ethane gas, and will be clinically worse, with frontal lobe aggression and impulsiveness rarely or never seen in kids pre-1899. They are all Phineas Gage mimics, but what's been through their brain is not a tamping iron, but refined seed oil. I have seen very good results in my ADHD child cases, simply by eliminating refined seed oils from the diet, and by adding some oily fish, or fish oil capsules. No such child, in my care, has ever needed ADHD medication.
Dr Mota-Castillo and his colleagues would have few cases--if any-- of ADHD, OD, CD etc., were it not for the widespread consumption of refined seed oils in the USA, since about 1920. Vacuum deodorization of smelly cottonseed and peanut oils was invented in Savannah, Georgia, in 1899, by food oil chemist David Wesson. These oils are low in vitamin E, which results in cerebral lipid peroxidation (eg. ADHD kids exhale ethane gas, a marker of such peroxidation: B Ross, 2003). Prenatal exposure results in a typical ADHD kid, plus a forgetful, photophobic mother, who takes sunglasses everywhere she goes. The same oils cause Alzheimer's in later life. Any ADHD kid still exposed to these common salad and frying oils in their daily diet will be exhaling ethane gas, and will be clinically worse, with frontal lobe aggression and impulsiveness rarely or never seen in kids pre-1899. They are all Phineas Gage mimics, but what's been through their brain is not a tamping iron, but refined seed oil. I have seen very good results in my ADHD child cases, simply by eliminating refined seed oils from the diet, and by adding some oily fish, or fish oil capsules. No such child, in my care, has ever needed ADHD medication.
We thank Psychiatric Times and Dr. Allen Frances for making the DSM-V's development an interesting debate to follow. However, we believe that Dr. Frances' invitation to the research community should also be extended to frontline clinicians like us, and we worry about the implicit infallibility assigned to the medical research community. In our view, the imminent perpetuation of several diagnostic artifacts included in DSM-IV-TR not only poses risks to the health and well-being of our patients, but also raises questions regarding the reliability of several diagnoses. As has been noted, (1,2,3), the psychoanalytic orientation of psychiatry at the time DSM-III and DSM-IV were created generated pseudo-diagnoses that are now used by the HMOs to deny inpatient treatment. These pseudo-diagnoses also contaminate data in expensive studies, such as the Multimodal Treatment Study of Children with ADHD (MTA) (4) Specifically: Oppositional-Defiant Disorder (ODD), Conduct Disorder (CD), Disruptive Disorder NOS, Borderline Personality Disorder (BPD), and Intermittent Explosive Disorder (IED) are labels that emerged as "solutions"to explain syndromes clinicians were observing in the 1970s and 80s. We believe that, in fact, psychiatrists were encountering social anxiety, obsessions, bipolar spectrum disorders, psychosis, PTSD, phobias, and even complications of sexual abuse in children--but were discouraged by the prevailing orthodoxy from identifying these conditions by their real names. Today, children with defiant and aggressive behavior due to pathologically elevated mood are called "ODD with comorbid ADHD," because they are restless and inattentive. We believe these symptoms are usually due to agitated manic states. Moreover, when these so-called "ADHD symptoms" are treated with amphetamines, the patient's condition typically worsens and may eventuate in assaultive behavior-at which point, the patient "graduates" to the additional diagnosis of Conduct Disorder! Worse still, the patient is then labeled "unruly" or "incorrigible" when he "refuses to change his behavior despite adequate treatment." In our collective experience, many such patients end up in Residential Treatment Centers and Juvenile Detention Centers. Sadly, we have found an abundance of such "violent kids" who are still prescribed stimulant medications while incarcerated. We also applaud Dr. Frances for addressing the "false epidemics of autism and attention-deficit-disorder," because we rarely see "heavy weight champions" joining the ranks of Hagop Akiskal,(5) Charles Huffine, Andy Pumariega and a few others, who have directly defied some of the DSM's diagnostic guidelines. We acknowledge that we lack randomized, controlled double-blind studies to confirm our observations-but we have many years of "eye-opening" experience that should not be ignored or considered irrelevant. Collectively, we manage the treatments of thousands of people whose lives have been transformed for the best by the diagnostic approach we advocate: avoiding the use of DSM labels like ODD, CD, BPD, and all the other "disorders" that are already explained by well-established diagnoses, for which we have effective treatments. Daniel Pistone, M.D. Manuel Mota-Castillo, M.D. Roberto Chaveve M.D. References: 1- Mota-Castillo, M., It is Really ODD?; Psychiatric Times Vol. 21, No. 3, 2004 2- Huffine, C., M.D. "Should the Conduct Disorder diagnosis be struck from the DSM-V?" Clinical Psychiatric News, Volume 28(4), 2000. 3- Atkins, D.L., Pumariega, A.J., Montgomery, L., Rogers, K., Nybro, C., Jeffers, G., Sease, F. Mental Health and Incarcerated Youth: Prevalence and Nature of Psychopathology. Journal of Child and Family Studies. 8(2): 193-204, 1999. 4- Akiskal, H., Demystifying borderline personality: critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum. Acta Psych Scand. Psych.; 110: 401-407, 2004 5- Jensen, P., M.D., Findings from the NIMH Multimodal Treatment of ADHD (MTA): Implications and Applications for Primary Care Providers; J. of Dev. & Behav. Ped., Vol 22, No. 1, 2001.