James Phillips, MD

[[{"type":"media","view_mode":"media_crop","fid":"41353","attributes":{"alt":"Â© Mariya Lavchieva/shutterstock.com","class":"media-image media-image-right","id":"media_crop_7257861830107","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4355","media_crop_rotate":"0","media_crop_scale_h":"185","media_crop_scale_w":"137","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© Mariya Lavchieva/shutterstock.com","typeof":"foaf:Image"}}]]If your concern as a clinician is how to code PTSD when we move to ICD-10-CM codes in October of this year, you need not fret. Simply go to the DSM-5 manual, find the PTSD diagnosis, and switch from the DSM-IV/ICD-9 309.81 to the ICD-10 F43.10. Do the same for acute stress disorder.

That simple maneuver, useful as it is for clinical practice, does hide some of the complexity of the new version of the manual. To begin with, DSM-5 has shuffled the deck and moved PTSD out of the anxiety disorders section, as in DSM-IV, and into a newly created section, trauma- and stress-related disorders. PTSD now keeps company with acute stress disorder, reactive attachment disorder, disinhibited social engagement disorder, all the adjustment disorders, other specified trauma- and stressor-related disorder, and unspecified trauma- and stressor-related disorder. Odd company, indeed. It’s as if the DSM-5 Work Group got stuck on the word “stress” in the PTSD acronym and decided that any diagnosis that includes this word belongs in the same section. Someone who experiences clinical anxiety in the context of a new job is now lumped into the same super-category as someone who has experienced a near-death on the battlefield.

What then is the reason for moving PTSD out of anxiety disorders and into the new trauma and stress disorders section? The main rationale is that PTSD often manifests with non-anxiety symptoms such as dissociative experiences, anger outbursts, and self-destructive behavior. As discussed below, however, patients with “complex PTSD” usually experience anxiety along with other symptoms. Given the imperfect fit of PTSD under anxiety or stress, we might conclude that the decision to choose one or the other is to some degree arbitrary.

The coding change is simple. What about the diagnostic criteria? By way of difference, DSM-5 specifies that the criteria apply to adults and children over age 6 (and includes another set of criteria for children under 6); eliminates the immediate response to the trauma as involving fear, helplessness, or horror; and splits the avoidance symptoms into 2 clusters (ie, distressing memories and external reminders). In addition to these changes, virtually all the symptoms of each cluster are elaborated or written differently, and for each cluster extra symptoms are added. More about this later.

In the years of DSM-5 development, one point of controversy in the work on PTSD was whether to include symptoms of complex PTSD (also called disorders of extreme stress not otherwise specified) in the diagnosis.

 The argument for inclusion was that many sufferers of trauma and chronic trauma do not experience the standard symptoms of PTSD but rather symptoms of depression, anxiety, or dissociation, or of borderline personality disorder. The authors of DSM-5 have handled this issue in a curious manner.

 To begin with, they eliminated criterion A2, which included the words “. . . response involved intense fear, helplessness, or horror,” explaining that “Emotional reactions to the traumatic event (eg, fear, helplessness, horror) are no longer a part of criterion A. The clinical presentation of PTSD varies.”

 The new criterion A does not, however, describe other possible reactions.

Where are the symptoms of complex PTSD? In the introductory paragraph to the trauma- and stressor-related disorders section, the authors write: “It is clear, however, that many individuals who have been exposed to a traumatic or stressful event exhibit a phenotype in which, rather than anxiety- or fear-based symptoms, the most prominent clinical characteristics are anhedonic and dysphoric symptoms, externalizing angry and aggressive symptoms, or dissociative symptoms.”

 So again, where in the manual are these symptoms? They get a one-sentence mention in the PTSD text but do not appear in the diagnostic criteria. Nor are they mentioned in the criteria or discussion section of either other specified trauma- and stressor-related disorder or unspecified trauma- and stressor- related disorder, in either of which we might expect them to appear. But finally, depression and aggression show up in reactive attachment disorder, another of the stress disorders. The problem is that this is defined as a diagnosis of children. We must conclude, therefore, that DSM-5 has hinted at symptoms of complex PTSD, but in the end has left them out of the manual. DSM-5 continues to opt for a universal reaction to stress, as presented in the diagnostic criteria.

 on PTSD as illustrative of DSM problems in cultural diversity. In that blog, I focused on research on the effects of political violence in Peru.5,6 In those studies, the McGill University researchers found a 25% incidence of classic PTSD symptoms among their victim research group but also a high incidence of depression and anxiety. Their findings were consistent with those of Hinton and Lewis-Fernandez,

 who reviewed the extensive research on PTSD in 2011 and concluded that the DSM-IV symptom cluster does have a degree of validity on its own, but that DSM-IV does not do justice to the great cultural variety of every aspect of response to trauma. In the DSM-5 discussion of PTSD, there is a small subsection, culture-related diagnostic issues, devoted to cultural differences. While this subsection does recognize cultural variation, and while DSM-5 also has an entire section III dedicated to “cultural formulation,” these commentaries do not alter the core diagnostic criteria of PTSD, which continue to convey the sense of a universal response to trauma. Thus, as with complex PTSD, DSM-5 has not significantly changed the problems with PTSD that beset DSM-IV.

What can we conclude about PTSD in DSM-5? Despite the efforts of a dedicated Work Group, DSM-5 has not fixed such major concerns of DSM-IV as complex PTSD and cultural variance; and these issues are in turn related to the DSM-5 insistence on a universal response to trauma as framed by the PTSD diagnostic criteria.

DSM-5 has introduced many changes in the wording of the PTSD diagnostic criteria, so many that the manual evokes an almost obsessive need to make things more precise, as if, in the uncertain area of psychological trauma and its consequences, DSM-5 will at all costs pin it down.

For the clinician who tries to diagnose using DSM, this could involve a time-consuming effort to get the criteria right. And given that experienced clinicians mostly diagnose through prototypes and not by counting criteria, and that there is no significant change in PTSD from DSM-IV, it is hard to imagine that the experienced clinician will pay much attention to the changes the Work Group has made.

Dr Phillips is Clinical Professor of Psychiatry in the department of social and behavioral health at the Yale Global Mental Health Program at the Yale School of Medicine in New Haven, CT.

 US Department of Veterans Affairs. PTSD: National Center for PTSD: Complex PTSD. 

http://www.ptsd.va.gov/professional/PTSD-overview/complex-ptsd.asp

 American Psychiatric Association. DSM-5 Development. G 03 Posttraumatic Stress Disorder. 

http://web.archive.org/web/20120504205134/http://www.dsm5.org/ProposedRevision/Pages/ proposedrevision.aspx?rid=165#PTSD

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

. Washington, DC: American Psychiatric Association; 2013.

 Phillips J. The cultural dimension of DSM-5: PTSD. 

http://www.psychiatrictimes.com/dsm-5-0/cultural-dimension-dsm-5-ptsd

 Pedersen D. Political violence, ethnic conflict, and contemporary wars: broad implications for health and social well-being. 

 Pedersen D, Tremblay J, Errazuriz C, Gamarra J. The sequelae of political violence: assessing trauma, suffering and dislocation in the Peruvian highlands. 

 Hinton DE, Lewis-Fernandez R. The cross-cultural validity of posttraumatic stress disorder: implications for DSM-5. 

Articles

Despite the efforts of a dedicated Work Group, DSM-5 has not significantly changed the problems with PTSD that beset DSM-IV.

PTSD in DSM-5: Understanding the Changes

With DSM-5 now approved by the APA Board of Trustees-and, to the dismay of this reader, all discussion removed from the DSM-5 Web site-how are we to evaluate the results of the field trials for the end product? I suggest beginning with the short piece published in 

 Authors David Kupfer and Helena Kraemer wrote, “We ultimately tested the criteria for 23 disorders. The question we asked was a straightforward one: In the hands of regular clinicians, assessing typically symptomatic patients in no different way than they would during everyday practice, was a particular disorder reliable?”



In responding to this statement, let me begin with a confession of ignorance. Since I was not a participant in the field trials-neither for DSM-5 nor for previous versions of the manual-I didn’t appreciate that the major purpose of the field trials was to test reliability of the diagnostic constructs. I labored under a nave illusion that since the ongoing crisis in the DSM has to do with diagnostic validity, field testing would somehow involve working on validity of new diagnoses. The “

” did hold out a little hope for work on validity with the statement: “Although some preliminary ‘convergent validity’ may be obtained in the field test (clinicians find the criteria fit syndromes expressed by real patients), a full test of the validity of these criteria will occur after DSM-V is published.”


Let me give a quick reminder of the relevant history. The goal of DSM-III was to establish diagnostic reliability through operational definitions and diagnostic criteria. It was assumed that psychiatric science would fill in and establish validity for the DSM-III diagnostic constructs. Thirty years later, as we were preparing for DSM-5, everyone acknowledged the great shock of the previous 3 decades: diagnostic validity for the DSM-III/IV diagnostic categories was in shambles. As the DSM-5 leaders wrote in the 2002 white paper, “

In the more than 30 years since the introduction of the Feighner criteria by Robins and Guze, which eventually led to DSM-III, the goal of validating these syndromes and discovering common etiologies has remained elusive. Despite many proposed candidates, not one laboratory marker has been found to be specific in identifying any of the DSM-defined syndromes. Epidemiologic and clinical studies have shown extremely high rates of comorbidities among the disorders, undermining the hypothesis that the syndromes represent distinct etiologies. Furthermore, epidemiologic studies have shown a high degree of short-term diagnostic instability for many disorders. With regard to treatment, lack of treatment specificity is the rule rather than the exception.



The authors’ response to this crisis was a vague appeal for a “

All these limitations in the current diagnostic paradigm suggest that research exclusively focused on refining the DSM-defined syndromes may never be successful in uncovering their underlying etiologies. For that to happen, an as yet unknown paradigm shift may need to occur. Therefore, another important goal of this volume is to transcend the limitations of the current DSM paradigm and to encourage a research agenda that goes beyond our current ways of thinking to attempt to integrate information from a wide variety of sources and technologies.



In the ensuing years, advances in neuroscience and genetics were still not validating the DSM-IV categories. The perfectly reasonable directives for the Work Groups outlined in the Guidelines mentioned above could not accomplish much without clear support from basic science. In the face of this limitation, the DSM-5 leadership moved to dimensional measures as one solution to the validity problem. In 2009 

The single most important precondition for moving forward to improve the clinical and scientific utility of DSM-V will be the incorporation of simple dimensional measures for assessing syndromes within broad diagnostic categories and supraordinate dimensions that cross current diagnostic boundaries. Thus, we have decided that one, if not the major, difference between DSM-IV and DSM-V will be the more prominent use of dimensional measures in DSM-V.



As the dimensional measures were being challenged (they were dismissed by the Board of Trustees in May of 2012), 

 moved to the NIMH Research Domain Criteria project as the ultimate salvation of DSM-5-almost implying that the RDoC project, developed independently of DSM-5 and the DSM categories because the categories don’t work for research, was somehow developed in conjunction with the DSM work:



A logical extension of those discussions, as detailed in our Research Agenda articles, is the Research Domain Criteria (RDoC) initiative recently launched by the National Institute of Mental Health (NIMH) . . . This NIMH objective is consistent with our research planning conferences and conclusions, which underscored our commitment to examining evidence from neurobiology and assessing the readiness of proposed revisions for DSM-5. We are pleased with the work on RDoC that is being undertaken, and we believe this initiative will be very informative for subsequent versions: DSM-5.1, DSM-5.2, and beyond…It is important to emphasize that DSM-5 does not represent a radical departure from the past, nor does it represent a radical separation from the goals of the RDoC.


So here we are, waiting for the appearance of DSM-5 in May, and being reassured that those new diagnoses that have survived the chopping block of the Board of Trustees and the Scientific Review Committee have been field tested and proven to be reliable. Isn’t this where we were in 1980 with the appearance of DSM-III-now another handful of new diagnoses with demonstrated reliability and minimal evidence of scientific validity? Since we still don’t have adequate validity for the existing ton of DSM-IV diagnostic categories, is there any reason to think that the new handful won’t suffer the fate of the DSM-III/IV categories-heterogeneity of presentation, fuzzy boundaries, excessive comorbidity, and failure of neuroscientific and genetic foundation. And we really can’t count on the RDoC to save the day for DSM-5.1, DSM-5.2, and beyond, given that the RDoC researchers are not working with DSM categories and have no expectation that the constructs for which they are seeking disruptions of neural circuitry will match up with existing diagnostic categories. If you check the working grid of RDoC, you won’t find a column for “DSM diagnosis.”

What did we learn from the DSM-5 field trials?


So what did we really learn from the DSM-5 Field Trials? We learned that with diagnostic criteria, it’s not that hard to assure diagnostic reliability. And that we now have such reliability for another small group of new diagnoses. But didn’t we already know from DSM-III that diagnostic reliability is fairly easy? How can one not respond to Kupfer and Kraemer: is that it?

 Kupfer D, Kraemer HC. What we learned from DSM-5 Field Trials. 

 2012;47:10. http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1391674.


Kendler K, Kupfer D, Narrow W, Phillips K, Fawcett J. Guidelines for making changes to DSM-V. Revised 10/21/09. 

http://www.dsm5.org/ProgressReports/Documents/Guidelines-for-Making-Changes-to-DSM_1.pdf

 Washington, DC: American Psychiatric Association Press; 2002.


 Regier DA, Narrow WE, Kuhl EA, Kupfer DJ. The conceptual development of DSM-V. 

 Kupfer DJ, Regier DA. Neuroscience, clinical evidence, and the future of psychiatric Classification in DSM-5. 

NIMH Research Domain Criteria Project (RDoC).


http://www.nimh.nih.gov/research-funding/rdoc/nimh-research-domain-criteria-rdoc.shtml

 National Institute of Mental Health Strategic Plan.


http://www.nimh.nih.gov/about/strategic-planning-reports/index.shtml

 Insel T, Cuthbert B, Garvey M, et al. Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. 

With DSM-5 now approved, all discussion has been removed from the DSM-5 Web site. According to the APA, the DSM-5 leadership moved to dimensional measures as one solution to the validity problem.

DSM-5 Field Trials: What Was Learned

[Editor's note: We owe an apology to Dr Paul Appelbaum, whose name erroneously appeared in a previously posted version of this article. The article now correctly includes the name of Dr Kenneth Appelbaum, a well known figure in forensic and correctional psychiatry. Our apologies to Dr Paul Appelbaum for this unfortunate error. The author would also like to extend a personal apology to Dr Paul Appelbaum for the error in the previously posted version of the article.]

In what will count as one of the more bizarre convergences of psychiatry and the law, a Massachusetts district court ruled recently that Robert Kosilek, a convicted murderer sentenced to life, has a constitutional right to receive a sex change operation at the public’s expense. Kosilek sued the Department of Corrections (DOC) over a violation of his constitutional rights because the DOC refused to pay for the operation. Judge Mark Wolf ruled in Kosilek’s favor, stating, “It is the only way to treat Kosilek’s ‘serious medical need.’”

 In his ruling Wolf noted that the Department of Correction’s own medical experts testified that they believe surgery was the only adequate treatment for Kosilek. Speaking of the prisoner’s anguish, Judge Wolf remarked, “[t]hat anguish alone constitutes a serious medical need. It also places him at high risk of killing himself if his major mental illness is not adequately treated.”

The case has caused a flurry of opposing opinions. Not surprisingly, transgender advocacy groups have praised the decision that Kosilek’s Eighth Amendment rights required the state to support and pay for sex reassignment surgery. On the other hand, both Republican Senator Scott Brown and Democratic candidate Elizabeth Warren have opposed the decision. Senator Brown called the decision “an outrageous abuse of taxpayer dollars,”

 and Senate candidate Warren said she didn’t think the ruling was “a good use of taxpayer dollars.” A group of 50 Massachusetts legislators asked the state Department of Corrections to appeal the ruling.

 reflected popular sentiment at the time of the first stages of the trial: “Kosilek’s case is not compelling for reasons even beyond the obvious distastefulness of a wife killer angling to serve out his sentence of life without parole in a women’s prison. Private insurers rarely pay for sex-change operations . . . Kosilek, like any inmate, deserves proper mental health care, including hormone treatment and expert therapy. If he is at risk of suicide, he should be placed under constant observation. But that’s sufficient.”


Judge Mark Wolf’s “Memorandum and Order on Eighth Amendment Claim,”

 (the Memorandum) begins with a statement that points to the essential role of psychiatrists and the diagnosis of gender identity disorder (GID) in the formation of his decision:

This case is unusual because a transsexual prisoner, plaintiff Michelle Kosilek, seeks an unprecedented court order requiring that the defendant Commissioner of the Massachusetts Department of Correction[s] . . . provide him with sex reassignment surgery to treat his major mental illness, severe gender identity disorder . . . Kosilek is serving a life sentence, without possibility of parole, for murdering his wife. Kosilek suffers from a [GID], which is recognized as a major mental Illness by the medical community and by the courts. Kosilek is, therefore, a transsexual-a man who truly believes that he is a female cruelly trapped in a male body. This belief has caused Kosilek to suffer intense mental anguish. This anguish has caused Kosilek to attempt to castrate himself and to attempt twice to kill himself while incarcerated, once while he was taking the antidepressant Prozac.

In Part I of the Memorandum, Judge Wolf provides a summary of the case, explaining that inmate Kosilek’s Eighth Amendment right to not undergo cruel and unjust punishment requires that he receive adequate medical care, and that for his condition, anything less than sex reassignment surgery is inadequate medical care and therefore cruel and unjust punishment. He signals in this opening summary that he relies on the Harry Benjamin Standards of Care in the development of his injunction on the State of Massachusetts to provide the sex reassignment surgery.

In Part II, “The Applicable Standards,” Judge Wolf traces the history of court rulings on the use of feminizing hormones, psychotherapy, and sex reassignment surgery in the prison system. He also notes that in 2010 the United States Tax Court held that the costs of feminizing hormones and sex reassignment surgery are for certain individuals tax deductible as forms of necessary “medical care” for a serious, debilitating condition that is sometimes associated with suicide and self-castration, rather than non-deductible expenses for “cosmetic” treatment. He concludes this section with the statement:

“To prevail in this case, Kosilek must prove that: (1) he has a serious medical need; (2) sex reassignment surgery is the only adequate treatment for it; (3) the defendant knows that Kosilek is at high risk of serious harm if he does not receive sex reassignment surgery; (4) the defendant has not denied that treatment because of good faith, reasonable security concerns or for any other legitimate penological purpose; and (5) the defendant’s unconstitutional conduct will continue in the future. If Kosilek proves that he is entitled to relief, the injunction issued must be narrowly tailored to remedy the violation of his Eighth Amendment rights and not unnecessarily restrict the discretion of prison officials.”

In Part III, “Findings of Fact and Conclusions of Law,” Judge Wolf details the first Kosilek trial in 2002 and the second-a 28-day bench trial heard by himself-in 2006, with testimony continuing until 2011. The second trial involved a major dispute among psychiatric experts.

As the DOC was under contract with the University of Massachusetts Correctional Health Program, they obtained the consultation of Dr Kenneth Appelbaum from the University of Massachusetts. Dr Appelbaum arranged for GID experts from the Fenway Clinic, Drs Randi Kaufman and Kevin Kapila, to consult on the question of sex reassignment surgery for the inmate. Both testified that Kosilek suffered from severe GID for which sex reassignment surgery was the necessary and appropriate treatment.

The DOC then engaged experts from outside the University of Massachusetts-Cynthia Osborne, a licensed social worker, and Dr Chester Schmidt, a psychiatrist-both associated with the Johns Hopkins Medical School. Both testified to the effect that the surgery was not medically necessary. The plaintiff engaged Dr George Brown, a psychiatrist on the Board of Directors of the Harry Benjamin International Gender Dysphoria Association, who testified to the necessity of surgery. The court requested that Dr Appelbaum review Dr Schmidt’s testimony in order to inform the court of his opinion as to whether Dr Schmidt’s recommendations were within “prudent professional standards.”

Judge Wolf expressed concern in his Memorandum that Osborne and Schmidt were under the influence of the Catholic, anti-surgery ideology of Hopkins’ ex-chair of psychiatry, Paul McHugh. (It apparently didn’t occur to Judge Wolf that the Fenway experts and the Harry Benjamin Association are also guided by their particular ideologies.) He stated, “. . . after consulting Drs Kaufman and Kapila, in whom he continued to have confidence, Dr Appelbaum concluded that ‘the recommendations of Dr Schmidt do not meet prudent professional standards.’”

The court then appointed Dr Stephen Levine as an expert witness and asked him to review Dr Schmidt’s recommendations. Dr Levine, who was chairman of the Harry Benjamin committee for the fifth version of the 

 reported that “Dr Schmidt’s view is within professional standards.”

 Under testimony, however, he qualified his report to the effect that Dr Schmidt’s view was prudent “only if, for some reason such as cost or the fact that Kosilek was incarcerated, sex reassignment surgery was not an option.” Now understanding the situation more clearly, he reversed the conclusion of his report.

Summarizing some of this conflicting testimony, Judge Wolf writes:

On May 10, 2005, UMass wrote that, “[w]e have consistently indicated . . . that we defer to the Fenway staff regarding the propriety of sexual reassignment surgery in the case of Michelle Kosilek.” And later, on June 14, 2005, that “[b]ased on the opinions of Dr Kapila and Dr Kaufman, and notwithstanding the report of Dr Osborne, we would again suggest that solely from a clinical perspective it appears that sex reassignment surgery should be offered to Michelle Kosilek.” On September 1, 2005, Drs Brown and Appelbaum wrote to the DOC that “[f]rom what we have been told by Dr Kapila and Dr Kaufman, it is our understanding that further delay in providing the recommended treatment likely will result in continued or increased levels of distress for each afflicted individual, with the possibility of self-inflicted injury. To that extent, we also view the treatment recommendations as medically necessary.”

In the final section of Part III, titled “Eighth Amendment Analysis,” Judge Wolf reviewed the 5 conditions Kosilek would have to prove to warrant the injunction requiring surgery. Judge Wolf concludes that Kosilek has proved the five conditions. In reviewing the second condition: “Sex Reassignment Surgery is the Only Adequate Treatment for Kosilek’s Serious Medical Need,” Wolf writes:

As indicated earlier, Drs Brown, Kaufman, and Forstein who each specialize in treating individuals with gender identity disorders, all testified that sex reassignment surgery is medically necessary for some individuals suffering from severe gender identity disorders. By contrast, Dr Schmidt testified that he disagreed with the Standards of Care to the extent that they provided that sex reassignment surgery is medically necessary for some transsexuals. 

The court finds the views of Drs Brown, Kaufman, and Forstein to be persuasive on the issue of whether such surgery is ever medically necessary. As previously described, the Standards of Care are accepted by prudent professionals in the community and provide that sex reassignment surgery is medically necessary for some individuals…the Fenway clinicians, Drs Kaufman and Kapila, wrote that “[g]iven her continued psychological distress, despite the treatment she has already had for GID in making a social and hormonal transition, sex reassignment surgery is the only treatment at this point that ameliorates Kosilek’s continued gender dysphoria.” Finding the opinions of Drs Kaufman and Kapila to be reliable, Dr Appelbaum concluded that sex reassignment surgery “is not only clinically appropriate and should be offered to Miss Kosilek, but…it is medically necessary.”


To say the least, the experience of psychiatry with sex related disorders has not been smooth. Problems go all the way back to 1973 when controversy over homosexuality was so intense that the question of removing the diagnosis from DSM-II was put to a membership vote. Dr Allen Frances has warned that the paraphilias are a minefield of “unintended consequences.”

 In reviewing his work as chair of the DSM-IV Task Force, he writes: “With one exception we made no obvious mistakes, but this one mistake was glaring and has caused great harm at the difficult boundary between psychiatry and the law. Sad to say, we did a very poor job in writing the DSM-IV paraphilia section, never anticipating that it would soon become central in determining the constitutionality of subjecting sexual offenders to lifelong psychiatric commitment. We carried over most of the already poor worded DSM-III-R text and inadvertently made it much worse with a seemingly small change (substituting an 'or' for an 'and'). The unintended consequences have been disastrous.”

 In the case of DSM-5, Dr Frances has focused on the dubious additions of “coercive paraphilia,” “hypersexuality,” and “hebephilia.” He may not have imagined the troubling possibilities for GID.

Given that the Kosilek decision was based entirely on the conclusion that Kosilek suffers from severe GID, we begin with a first, fundamental question: is GID a psychiatric disorder? Of course it was for DSM-IV, but that is less clear for DSM-5, in which Gender Identity Disorder has been demoted to Gender Dysphoria. The context for that change is the prominent campaign, as with many sex related conditions, to destigmatize the condition by removing it from the DSM. A typical example of the argument for removal is this statement of the National Committee on Lesbian, Gay, Bisexual, and Transgender Issues (NCLGBTI) of the National Association of Social Workers (NASW)

Respectfully, the [NASW-NCLGBTI] holds a position that Gender Identity Disorder, Gender Incongruence, Gender Dysphoria, Transvestic Fetishism, and Transvestic Disorder should not be considered as mental health diagnoses and therefore should be eliminated from the Diagnostic Statistical Manual (DSM). 

The NASW-NCLGBTI holds the position that the Gender Identity Disorder, Gender Incongruence, and Gender Dysphoria should be viewed and approached from the perspective of a medical model rather than that of a mental health model. Many anatomical inconsistencies now can be corrected surgically or chemically to align with the experienced true self. A medical diagnosis for transgender individuals, whose self-experienced gender does not match the sex assigned at birth and who require medical services to align the body with the experienced self, is more appropriate and consistent with research and best practices than a mental health diagnosis.

The DSM-5 response to this campaign has been to replace GID with Gender Dysphoria, thus removing the stigma of calling it a disorder-following the same path as homosexuality in the 1970s. The DSM-5 Work Groups have been criticized (by this author among others) for creating new diagnoses and medicalizing normality; in this instance, however, they have moved in the opposite direction-that of normalizing what in DSM-IV had been labeled a psychiatric disorder. The lengthy discussion in the DSM-5 Web site of whether to remove the “disorder” label and change GID to Gender Dysphoria is a masterful exercise in equivocation, uncertainty, and confusion (cf 

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=482#

). But given the bewilderment over how to treat this and other sex related diagnoses, such indecisive and unsettling discussion is entirely appropriate. The DSM-5 Work Group elected to remove GID and replace it with Gender Dysphoria, but they couldn’t bring themselves to remove the condition from DSM-5 and leave it as a medical condition that could cause clinical depression. Needless to say, as with other value-laden diagnoses, there is no scientific way to decide whether GID or Gender Dysphoria is or is not a psychiatric illness.

For the proponents of removing the GID diagnosis, the challenge has been to achieve 2 potentially conflicting goals: remove GID from the DSM, but at the same time argue for reassignment surgery. Their approach has in fact been rather straightforward, as suggested in the quote from the NASW: stop thinking of GID as a psychiatric condition and treat it as any other medical condition involving an anatomical abnormality that can be corrected by surgery.

 Their approach is in that way different from the way in which homosexuality was dealt with. They don’t want to “demedicalize” GID: they want to “depsychiatrize” it and in fact to “medicalize” it.

This approach to GID poses a real challenge to the field of psychiatry and the architects of DSM-5. The very structure of the DSM puts all disorders on some kind of equal status. Thus, Judge Wolf stands on solid DSM-IV ground when he argues that the inmate suffers from a major mental illness. But do we really think that a hallucinating schizophrenic and a person with GID have equivalent “illnesses”?

To appreciate the difference, consider the following. One person experiences hallucinations, delusions, and other symptoms of schizophrenia, but denies that he has schizophrenia or any other mental illness. We will probably continue to diagnose him as schizophrenic. Another person with symptoms of GID and the money to pay for reassignment surgery goes about correcting his anatomical/physiological problem, and he objects to our labeling him as suffering from a mental illness. Are we really going to tell him that, like the schizophrenic, he suffers from a mental illness and is just denying it? In their shift from GID to Gender Dsyphoria, the DSM-5 authors have effectively removed its parity with major disorders like schizophrenia.


Judge Wolf concluded that inmate Kosilek had an Eighth Amendment right to sex reassignment surgery because prominent psychiatrists argued that he suffered from a severe mental illness for which the appropriate and necessary treatment was sex reassignment surgery. The entire case was based on a putative psychiatric diagnosis, GID, which is about to be changed in DSM-5 to Gender Dysphoria, a diagnosis that for DSM-5 doesn’t warrant the label “disorder.” We can wonder, after psychiatry’s disastrous experiences with homosexuality and the violent sexual predator statutes, why the plaintiff psychiatrists would allow themselves to be sucked into this morass of another dubious, value-driven, sex-related diagnosis? Does psychiatry need to look foolish one more time for its diagnostic overreaching?

To appreciate the slippery slope onto which the psychiatrists have innocently stumbled, let’s imagine another situation. The prisoner is now someone suffering from Body Dysmorphic Disorder who is convinced that his breasts are too large and make him feel like a woman. He is distressed to the point of feeling suicidal over his inability to correct this defect surgically. Will we as psychiatrists testify that such surgery is the appropriate and necessary treatment for his condition? Or will we argue that such surgery is not medically necessary and qualifies merely as “cosmetic” surgery?

Judge Wolf would probably support the latter opinion, noting in his memorandum that “the United States Tax Court held that the costs of feminizing hormones and sex reassignment surgery are for certain individuals tax deductible as forms of necessary ‘medical care’ for a serious, debilitation condition that is sometimes associated with suicide and self-castration, rather than non-deductible expenses for ‘cosmetic” treatment.’”

 The problem with this argument is that while GID will be demoted in DSM-5 to less than a disorder, Body Dysmorphic Disorder will remain a disorder, thus enjoying higher status as a “major mental illness” than Gender Dysphoria. So if the team of psychiatrists who testified for the medical necessity of inmate Kosilek’s surgery are called back to court to weigh in on another prisoner’s suicidal body dysmorphic disorder, consistence may oblige them to testify for the medical necessity of the corrective surgery.

How much cleaner it would have been for Dr Appelbaum and colleagues to say, this is a questionable, value-driven diagnosis, for which we don’t have any final word, much less a clear recommendation for what treatment is necessary other than to treat the man’s depression; we can’t argue for the medical necessity of sex reassignment surgery any more than we could for the medical necessity of forgiving a man’s mortgage because the prospect of foreclosure was making him suicidal. They could also recommend that, given the uncertain psychiatric status of Kosilek’s condition, it should be treated medically like any other physical abnormality-cleft pallet, club foot, whatever-and that questions as to whether such conditions should be paid for by the state in which the inmate is imprisoned are not the province of psychiatric expertise.

For inmate Kosilek, the bottom-line issue is whether the state has an Eighth Amendment obligation to pay for sex reassignment surgery. In coming to his conclusion the judge relied on the opinions of psychiatric experts and the Harry Benjamin Standards of Care. The latter are a product of the Harry Benjamin International Gender Dysphoria Association, Inc., which supports sex reassignment surgery for appropriately designated individuals. The standards also emphasize the need of a psychiatric diagnosis: “The use of a formal diagnosis is an important step in offering relief, providing health insurance coverage, and generating research to provide more effective future treatments.”

 Thus, like the expert psychiatrists, they depend for their recommendations on a diagnosis that is about to disappear.

There is of course a distinction to be made between the appropriateness of care and whether it should be paid for by insurance or other parties. As judge Wolf notes, “ . . . the fact that an inmate is entitled to adequate medical care does not mean that he is entitled to ideal care or to the care of his choice.”

 We experience this issue all the time in the question of psychotherapy, eg, whether the psychotherapy, however appropriate, meets the insurance company’s standard of medical necessity and thus warrants insurance company support. In general, when we (or an insurance company) seek a standard for what should be covered and what not, we turn to Medicare and its coverage policies. In the present discussion it is thus significant that Medicare does NOT cover sex reassignment surgery. This was pointed out in a recent 

 commenting on the Kosilek case and titled “Sex Change at Taxpayer’s Expense”:

A Massachusetts judge went too far in ruling that the state should pay for such surgery for convicted murderer Michelle Kosilek. Though the psychiatric world recognizes and treats gender identity disorder-defined by the 

 as a disconnect between a person’s physical gender and the gender the person identifies with-that recognition hasn't translated into widespread insurance coverage for sex-change operations that some patients feel is the only solution to their turmoil. Most private insurance and Medicaid programs do not pay for the surgery, viewing it as elective; neither does Medicare.

In summary, then, Judge Wolf has invoked the Eighth Amendment to require the State of Massachusetts to pay for sex reassignment surgery for a sentenced murderer, basing his judgment on a disputed psychiatric diagnosis that may disappear from the soon-to-appear DSM-5, and requiring from the State of Massachusetts a payment policy not allowed by Medicare for ordinary citizens. His questionable judgment is matched only by the psychiatric experts, who may again have led psychiatry down the slippery slope of diagnostic overreaching.

http://pacer.mad.uscourts.gov/dc/cgi-bin/recentops.pl?filename=wolf/pdf/kosilek%20eighth%20amendment%20decision.pdf

.  Accessed September 27, 2012.
2. Associated Press. Sen. Scott Brown calls inmate sex-change ruling “an  outrageous abuse of taxpayer dollars;” advocates praise ruling. September 5,  2012. 

 http://www.masslive.com/news/index.ssf/2012/09/sen_scott_brown_calls_inmate_s.html

.  Accessed September 27, 2012.
3. McNamara E. When gender isn't relevant. 

http://www.boston.com/news/local/articles/2006/06/11/when_gender_isnt_relevant/

.  Accessed September 27, 2012.
4. Harry Benjamin International Gender Dysphoria  Association.

 The Standards of Care for Gender Identity Disorders (Fifth  Version)

. DÃ¼sseldorf:Symposion Publishing; 1998. 

 http://www.tc.umn.edu/~colem001/hbigda/hstndrd.htm

. Accessed September 27,  2012. 
6. First M, Frances A. Issues for DSM-V: unintended  consequences of small changes: the case of paraphilias. 

 2008;165:1240-1241.
5. Frances A. The risk that DSM-5 will exacerbate  the SVP mess in  forensic psychiatry. In: Phillips J, Frances A. The seven  biggest risks  posed by DSM-5. 

http://www.benthamscience.com/cpsr/HT/Allen-Frances.pdf

. Accessed September 27,  2012.
7. Frances A. A warning sign on the road to DSM-V:  Beware of Its unintended consequences. 

http://www.psychiatrictimes.com/display/article/10168/1425378

. Accessed  September 27, 2012.
8. First MB, Halon RL. Use of DSM paraphilia  diagnoses in sexually violent predator commitment cases. 

 2008;36:443-454.
9. Frances A, Sreenivasan S. Sexually violent  predator statutes: the clinical/legal interface. 

http://www.psychiatrictimes.com/display/article/10168/1357827

.  Accessed September 27, 2012.
10. Frances A, Sreenivasan S, Weinberger LE.  Defining mental disorder when it really counts: DSM-IV-TR and SVP/SDP statutes. 

 2008;36:375-84..
11. National Association of Social Workers. Gender  Identity Disorder and the DSM.Â   

http://www.socialworkers.org/diversity/new/lgbtq/51810.asp

. Accessed  September 27, 2012.
12. Editorial. Sex change at taxpayer expense? 

http://articles.latimes.com/2012/sep/13/opinion/la-ed-prison-sex-change-20120913

.  Accessed September 27, 2012.
13. A.D.A.M. Medical Encyclopedia. Gender identity  disorder. 

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002495/

A recent case has caused a flurry of opposing opinions. Not surprisingly, transgender advocacy groups have praised the judge's decision that the inmate in question has an eighth amendment right requiring the state to support and pay for sex reassignment surgery.

Gender Identity Disorder in Prison: Depending on a Diagnosis That Is Soon to Disappear?

With DSM-5 scheduled for publication a little more than a year from now, we may safely assume that barring unannounced surprises from, say, the APA Scientific Review Committee, what we will see on the DSM-5 Web site is what we will get. With that in mind, it’s time to review what we will indeed get. But before moving to significant changes in the major disorder categories, we should remind ourselves where DSM-5 fits into the larger picture of coding mental illnesses.

There are, in case you have forgotten, two classificatory systems of mental disorders-the International Classification of Diseases (ICD), produced by the World Health Organization (WHO), and the Diagnostic and Statistical Manual (DSM), produced by the American Psychiatric Association. How are they related? It is a question that has confused me, and I assume, some of my psychiatric colleagues as well as others-other mental health professionals, and still others. For an answer to this question, I asked Michael First, MD, Editor of DSM-IV-TR, Consultant on the WHO ICD-11 revision, and someone who knows much more about these matters than most of us. Here is his response to what I put as a question that could lend itself to a quick answer.

I wish I could give you a quick answer, but as with any question about the coding, I need to give the background first.

This is how it works. The only official coding system in the United States is the ICD, produced by the WHO. The US has a treaty obligation to report health statistics using the ICD system. The US is still using a "clinical modification" of the WHO's ICD-9 system (released in 1978) called ICD-9-CM. The diagnostic codes that appear in the DSM-IV are all legal ICD-9-CM codes. Clinicians fulfill their obligations to use the ICD-9-CM coding system by using the DSM-IV. When DSM-IV created its few new disorders, which were obviously not in the ICD-9-CM, the APA could either assign an existing ICD-9-CM code (which might be already used for another DSM-IV disorder, in which case multiple disorders would share the same code), or else request that the US Government to add a new code to the ICD-9-CM system (such a provision exists in the ICD-9-CM system to accommodate newly discovered or new subtypes of diseases), which is a year-long process.

When assigning an existing code, we would pick the code that was closest to the phenomenology of the new disorder. For example, ICD-9-CM had a code for "depressive neurosis," which was then assigned to the DSM-III disorder "dysthymia," because that ICD-9-CM concept came closest to the DSM-III concept. More often, for a category that was not really reflected in the ICD-9-CM at all, we would assign an "other" code, which are available throughout the ICD-9-CM precisely to accommodate the addition of new disorders. So for Bipolar II Disorder, which we added to DSM-IV, we picked the code 296.89, which corresponded to "Other Bipolar Disorder" in ICD-9-CM.

For DSM-5, the same general rule applies. For new diagnoses such as Attentuated Psychosis Syndrome, APA would need to look at the existing system and either find some category that corresponded most closely to this condition (although it is not clear to me that there is any such condition already in ICD-9-CM), or else assign some "other" code; perhaps the code for "Other Psychotic Disorder," although even that would be a stretch since, by definition, these individuals are not psychotic. Even though the newly assigned code may not up conceptually match very well to the existing ICD-9-CM entity, from a practical perspective it doesn't matter-insurance companies seem to accept and pay for most ICD-9-CM codes no matter what they are, unless they have been specifically excluded by the insurance company. For example, perhaps an insurance company would want to refuse payment for treatment of personality disorders; they could exclude any of the codes for personality disorders.

Further complicating matters is the recent news that implementation of ICD-10-CM is being delayed from October 2013 to God knows when. Originally, DSM-5 was planning to include ICD-10-CM codes to be compatible with the requirement that clinicians use ICD-10-CM codes starting in October 2013 (5 months after publication of DSM-5). Now that there will be a delay, DSM-5 will need to use ICD-9-CM codes (ie, those in the DSM-IV), instead.

So welcome to the Byzantine process of psychiatric coding. Further implications of the above are that (1) it’s not legitimate to use ICD-10 codes in the US, although they are used in the rest of the world, and (2) you may use any ICD-9-CM code, even if it’s not in the DSM-IV.

For those of you who are interested in diagnostic coding parlor games, this situation leaves you with two such games. First, take your guess as to what ICD-9 code will be dragooned to cover DSM-5 diagnoses such as Attenuated Psychosis Syndrome and Disruptive Mood Dysregulation Disorder (as you saw above, Michael First already stated his guess for APS). And second, take a tour through that 1978 document, ICD-9-CM, and see whether there are any diagnoses left out of DSM-III and IV that you would like to add to your personal arsenal.

With DSM-5 scheduled for publication a little more than a year from now, we may safely assume that, barring unannounced surprises from, say, the APA Scientific Review Committee, what we will see on the DSM-5 Web site is what we will get. With that in mind it’s time to review what we will indeed get. 

DSM-5 in the Homestretch-1. Integrating the Coding Systems

 have recently heralded the  proposed DSM-5 revision for diagnosis of personality disorders. The end product  of much dodging and weaving on the part of the Work Group (eg, narcissistic  personality out/narcissistic personality disorder back in), the revision is  touted to resolve problems inherent in the DSM-IV treatment of personality  disorders: it recognizes the dimensional character of personality traits and  disorders, and it moves beyond the dichotomous (present or absent) strictures  of DSM-IV diagnosis.

Those  accomplishments granted, the news is not all good regarding the new model. A  good look at the DSM-5 Web site (I wanted to say a “quick” look, but a quick  look will leave you deeply confused) reveals a degree of complexity worthy of  the finest medieval scholastic philosophers. If the current version seems  disorienting, bear in mind that it was worse. The DSM-5 site notes, remarkably,  that “Since its original posting on the APA’s DSM-5 Web site in February  of 2010, all parts of the model have been simplified and streamlined in  response to comments received and to critiques in the published literature.”

The site also informs us that “The goal of the new criteria is to maximize their utility to clinicians  and benefit to patients.” And the 

 article quotes Drs  Oldham and Skodol as saying that “the system will require some training, but  that once clinicians familiarize themselves with the criteria, they will find  the system easier to use than DSM-IV, more intuitive, and more reliably  concordant with the clinical presentation of patients with personality  disorders."

 Surely they jest-but judge for yourself.


   In this posting I want to focus on the unwieldy complexity  of the new Personality Disorders section, but first let me note the revised  list of personality disorders. The work group reduced the DSM-IV list from 10  to 5 (and then to 6, when narcissistic personality disorder was reintroduced  following objections from the rank and file).

For each of the disorders removed from the DSM-5 list the  explanation given is that “The Work Group recommends  that this disorder be represented and diagnosed by a combination of core impairment  in personality functioning and specific pathological personality traits, rather  than as a specific type.” Anyone wondering how the decisions were made  is on his own. For this reader at least, paranoid personality disorder  (removed) is a readily identified personality disorder, and easily as worthy of  inclusion as avoidant personality disorder (retained).


   The assessment begins with Criterion A, Level of Personality  Function, presumably to be part of every patient’s evaluation. The Levels of  Personality Function Scale is a five-point rating scale for two domains of  personality functioning-Self and Interpersonal. Under Self are subdivisions of  Identity and Self-direction, and under Interpersonal are Empathy and Intimacy.  This criterion will let us know whether and to what degree any patient has a  personality dysfunction. Aside from issues of uncertain scientific foundation  and laborious implementation, this scale is notable for its reintroduction of  psychological and psychodynamic features that had been banned from DSM-III.  Assessing someone’s capacity for empathy is not the same as checking for  sadness or insomnia, and will take considerably more time as well as  psychological sensitivity. I can ask someone if he feels sad, but I’ll have to  talk to him at some length to determine his capacity for empathy.

Criterion B moves from general  personality dysfunction to presence of one of the six disorders. Rather than  just naming the criteria for each personality disorder, this criterion uses  another architectonic structure in which pathological personality traits are  assessed under five broad personality trait domains-negative affectivity,  detachment, antagonism, disinhibition versus compulsivity, and psychoticism, as  well as component train facets like impulsivity and rigid perfectionism for  each of the five trait domains. Needless to say, another scale, the 4-point  Personality Trait Rating Form, is administered to score the individual on these  traits, and the particular personality disorder is defined in terms of  particular trait clusters. (Are you confused? Just remember the reassurance  that you will find it easier than DSM-IV.)

To deal with the person with  significant personality disturbance who does not reach the threshold for a particular  personality disorder, a diagnosis of Personality Disorder Train Specified  (PDTS) can be given along with the relevant traits.


   There is something quite elegant  about the DSM-5 Personality Disorders diagnostic system-an architectonic of  divisions, subdivisions, and sub-subdivisions. On the other hand, for all their  scholastic erudition, the work group have created a monster-a bloated,  pedantic, cumbersome diagnostic instrument that will never be used by anyone  working in the hurly-burly of clinical practice. Just imagine doing a routine  new-patient evaluation and trying to include the personality disorder  assessment, each of the first two criteria with its many-item scale, each item  to be scored on a 4- or 5-point rating system. It’s hard to imagine anyone  having the patience or motivation to use this instrument.

As I indicated above, the DSM-5 Web site assures us that “The proposed system is  designed for flexible use to maximize clinical utility.” Who could make such an  out-of-touch statement about this instrument, and who could construct such an  instrument under the remarkable notion that it will be clinically useful? The  answer is simple: experts-or I should say, well-intentioned experts, scholarly  psychiatrists who have worked intensively in this area and want to inform the  new manual with the benefits of their expertise.

What  they lack, of course, is common sense-the ability to limit the implementation  of their knowledge to what is practical useful. If we were starting over with  the Work Groups, the biggest improvement would be to appoint a number of  non-experts to each group-individuals with real-world experience who could say  to the experts, this is a brilliant idea, but it’s totally impractical for the  ordinary working clinician.

To  illustrate, let’s take an example-borderline personality disorder (BPD). Start  with the ICD-10, which offers a 100-word description of the disorder,  highlighting the main features. The ICD-10 definition would be adequate for  most clinicians and in fact reflects how most of us work. It would of course  take a fraction of the time as the DSM-5 assessment.

Now  let’s move on to DSM-IV. The manual lists 9 diagnostic criteria for BPD. The  patient must meet 5 or more of the criteria to warrant the diagnosis. This  approach to diagnosis has been criticized for requiring a categorical,  dichotomous yes-or-no decision on the diagnosis, eliminating any possibility of  a dimensional assessment that would permit diagnosing subthreshold, mild  conditions. This flaw in the DSM-IV approach has been the principal argument  for the elaborate dimensional approach of DSM-5, which allows the clinician to  make the diagnosis along a continuum ranging from mild to severe forms of BPD.

Given  the sheer impracticability of the DSM-5 model, what are our alternatives? We  could take the simple ICD-10 approach. We could stick with DSM-IV and its  flaws. If we wanted to address the flaws of DSM-IV, we could look for a simpler  dimensional model than DSM-5. As it turns out, one has just been offered us. In  a recent publication

), Mark Zimmerman  and colleagues have demonstrated in a thorough study of 2150 psychiatric  outpatients that one could easily use the DSM-IV NOS category (with traits  specified) to create a simple 3-point dimensional assessment with categories of  absent, subthreshold traits, and present.

Using  this makeshift DSM-IV dimensional assessment for personality disorders, they  demonstrated that “There was no difference between the 3-point, 5-point, and  criterion count methods of scoring the DSM-IV personality disorder dimensions .  . . The DSM-IV 3-point rating convention was as valid as scoring methods using  more finely graded levels of severity.” In the case of our example of borderline  personality disorder, this method would allow for BPD, no BPD, and mild,  subthreshold traits of BPD.

We  now have two alternatives to the unmanageable system of DSM-5. We could elect  for real simplicity and use ICD-10, or if we want a dimensional component with  mild, subthreshold diagnoses, we could use the Zimmermann modification of  DSM-IV. Either would allow for quick assessment and spare us the extraordinary  time and labor required by the DSM-5 model (The ICD-10 system, with its own NOS  category, could easily be modified a la Zimmermann to produce another simple,  3-point dimensional model.).

In  the face of these alternatives, it is hard to justify adopting the DSM-5  proposal. One more time, a huge effort by well-intentioned experts that has  produced an unwieldy, impractical instrument that will be used by no one.

American Psychiatric Association. DSM-5 Revisions  for Personality Disorders Reflect Major Change: Public Comment Period for  Proposed Diagnostic Criteria Extended Through July 15. Press release: July 7,  2011. 

http://www.dsm5.org/Newsroom/Documents/DSM-5-Revisions-for-Personality-Disorders-Reflect-Major-Change-.pdf

 Moran M. 2011. DSM-5 Developers Propose New System for Diagnosing Personality  Disorders. 

http://psychnews.psychiatryonline.org/newsArticle.aspx?articleid=116625

American Psychiatric Association DSM-5  Development. Personality Disorders. 

http://www.dsm5.org/ProposedRevision/Pages/PersonalityDisorders.aspx

 Zimmerman M, Chelminski I, Young D, et al. Does DSM-IV already capture  the dimensional nature of personality disorders? 

Frances A. An alternative to the DSM-5  personality proposals. 

http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1959616

Both the DSM-5 Web site and Psychiatry News  have recently heralded the proposed DSM-5 revision for diagnosis of personality disorders. 

The Great DSM-5 Personality Bazaar

In a commentary in the July, 2011 issue of the 

 David Kupfer and Darrel Regier, Chair and Vice-chair of the DSM-5 Task Force, have provided us with a current status report on DSM-5, now in field-trial phase and scheduled for publication in 2013. We can certainly thank them for their effort to bring us up to date; but regretfully, if we are to judge the progress of DSM-5 by the incoherence of their commentary, we have a lot to worry about.

I am of course aware that in labeling the commentary as incoherent, I am using a strong and unflattering adjective. I hope to demonstrate that the commentary warrants that adjective.

In most general terms, the incoherence involves the authors’ account of DSM history. They informed us in 

 in 2002 that the diagnostic constructs of DSM-III and DSM-IV had reached a crisis of validity and that to meet that challenge, DSM-5 would require a “paradigm shift.” In the intervening years, however, the paradigm shift in the DSM-5 work was not accomplished, and the authors have now shifted to a “Whiggish” narrative of a steady march forward (without paradigm shift) from Robins and Guze to DSM-5 and beyond. Let me spell this out in some detail.

 after detailing the failure of ongoing research to meet the Robins and Guze validation requirements for DSM-IV diagnostic categories, the authors wrote:

In the initial stages of development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), we expected that some of the limitations of the current psychiatric diagnostic criteria and taxonomy would be mitigated by the integration of validators derived from scientific advances in the last few decades. Throughout the last 25 years of psychiatric research, findings from genetics, neuroimaging, cognitive science, and pathophysiology have yielded important insights into diagnosis and treatment approaches for some debilitating mental disorders, including depression, schizophrenia, and bipolar disorder.

 we anticipated that these emerging diagnostic and treatment advances would impact the diagnosis and classification of mental disorders faster than what has actually occurred. This optimism was not wasted, however.

The authors support their optimism with recent neuroscientific work on a “stress-induced and fear circuitry spectrum” that groups a number of phenotypically heterogeneous anxiety disorders with a common circuitry disruption, the proposal of 11 external validators to aid in grouping disorders, and further expected finding from the NIMH Research Domain Criteria (RDoC) project.

So we have reason to be optimistic because neuroscience and genetics are making progress (although it is not clear what that has to do with DSM-5). Toward the end of the Commentary the authors summarize that “[i]t is important to emphasize that DSM-5 does not represent a radical departure from the past, nor does it represent a radical separation from the goals of the RDoC. As we gradually build on our knowledge of mental disorders, we begin bridging the gap between what lies behind us (presumed etiologies based on phenomenology) and what we hope lies ahead (identifiable pathophysiologic etiologies)”

So, what is confusing or incoherent in this picture? First, how are we supposed to understand the just quoted sentence? From all available evidence the distance between DSM-III and the post-RDoC DSM will be profound - indeed, it will be the paradigm shift adumbrated in 

, just not realized in DSM-5. We know that the Robins/Guze criteria for validation will not be realized. And we have very little idea how diagnostic categories of the future will be defined and grouped, what will be left of the DSM-III and DSM-IV categories, or how neuroscientific and genetic findings will match up with the older phenomenological, descriptive categories. Kendler has warned us not to expect anything simple and straightforward from genetics.

 In the face of all this uncertainty the authors wish to place DSM-5 comfortably between DSM-III/IV and the post-RDoC DSM, with no significant break in either direction. What could that possibly mean?

Second, we can look at what the authors actually propose for DSM-5. They mention two categorical changes: the proposal for a single “autism spectrum disorder” and the proposal for an “attenuated psychosis syndrome.” They do not mention the controversies surrounding these diagnostic categories, involving the question of creating populations of false-positive patients who would be subjected both to diagnostic mislabeling and unwarranted, potent medications.

Also, in addition to not mentioning the many other proposed categorical changes in DSM-5-some controversial (eg, the low sexual interest disorders for men and women), others not-the authors do not mention what in their 2009 commentary/update they called the major innovation of DSM-5. In that piece they wrote that “The single most important precondition for moving forward to improve the clinical and scientific utility of DSM-V will be the incorporation of simple dimensional measures for assessing syndromes within broad diagnostic categories and supraordinate dimensions that cross current diagnostic boundaries. Thus, we have decided that one, if not the major, difference between DSM-IV and DSM-V will be the more prominent use of dimensional measures in DSM-V.”

Where have these dimensions gone? Oddly, they seem to have disappeared from the DSM-5 Web site. In earlier versions the dimensional measured figured prominently, prompting me to write a blog expressing my own skepticism toward them.

 But in the current Web site, I could only find a trace of them as a topic of the Diagnostic Assessment Instruments Study Group. I am left wondering whether the “major change” is alive but not being talked about, or whether it is a victim of an unannounced euthanasia.

The above changes relate only minimally to the anticipated findings from neuroscience and genetics. The authors bring in this science of the future in the following manner: “...our recognition of the significance of neuroscience and genetics in psychiatric diagnosis has supported DSM-5's novel integration of neurobiological findings, such as inclusion within the text that accompanies diagnostic criteria sets the potential role of these factors in shaping risk and prognosis. While not central to the criteria themselves, this information is nonetheless useful and informative for helping DSM provide a more precise picture of the clinical realities of psychiatric diagnosis.”

 For an idea that the authors call “novel,” I can think of a couple other words. One would be “wild.” The other would be “desperate” - to link DSM-5 to the coming science. To take them at their word, they are actually proposing to incorporate what we presume to be inchoate, untested findings from the new neuroscience into DSM criteria text (as opposed to, say, letting those findings simmer in the oven for a few years to see if they’re worth anything). To take the example of the “stress-induced and fear circuitry spectrum,” this is an early finding, and we have no idea whatsoever what role it will play in diagnosis and treatment. Do we really want to include it in the diagnostic criteria text?

How can we summarize the authors’ Commentary? Although by their account (in 

), the DSM-III/IV diagnostic constructs haven’t and won’t achieve the Robins/Guze standards of validity, and although the hoped-for answers from the RDoC project are too distant to play a significant role in DSM-5, they describe a course of unbroken progress from DSM-III/IV, through DSM-5, to whatever lies ahead, for our nosology. For DSM-5's role they mention a couple changes, leave out the formerly touted dimensional measures, and provide the link to the post-RDoC DSM by incorporating early neuroscientific findings into the DSM-5 diagnostic criteria text. They have replaced the image of a paradigm shift in DSM-5 with a narrative of DSM-5’s providing a smooth (however unexplained and incoherent) transition to the neuroscience of the future. I would submit that this Commentary does not inspire confidence in DSM-5.

So what should we do? In the semi-official publication from this year, 

Regretfully, if we are to judge the progress of DSM-5 by the incoherence of a recent commentary by the Chair and Vice-chair of the DSM-5 Task Force, we have a lot to worry about.

Author | James Phillips, MD

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