DSM

Below is an editorial (with the above title) taken from the newsletter of the Society of Biological Psychiatry and written by its editor Stephen M. Strakowski MD.

In preparing DSM-IV, we worked hard to avoid causing confusion in forensic settings. Realizing that lawyers read documents in their own special way, we had a panel of forensic psychiatrists go over every word to reduce the risks that DSM IV could be misused in the courts.

The DSM-5 attempt to “dimensionalize” the diagnosis of personality disorder has worthy goals, but has suffered from grievously incompetent implementation.

I recently experienced the odd coincidence of receiving 2 separate emails on the same morning each asking almost the very same question. . . how can I remain so high on psychiatry while at the same time being so critical of some of its recent trends and so fearful of the likely future harmful impact of DSM-5?

A newly appointed DSM-5 scientific review group is meant to “review the reviews”-but it is working in secret and so far appears to be a remarkably porous filter . . .DSM-5 has shown no capacity to self-monitor and self-correct. An outside review is sorely needed-and fortunately a ready mechanism is in place.

I just read a blog by Dr Dayle Jones that could have an important influence in the endgame effort to save DSM-5 from itself.

Psychiatric symptoms are fairly ubiquitous in the general population- most normal people have at least one, many have a few. When present in isolation, a single symptom (or even a few) does not a psychiatric disorder make. Two additional conditions must also be met before a symptom can be considered to be part of a mental disorder.

Psychosis Risk (AKA attenuated psychotic symptoms disorder) has always had 3 strikes against it.

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.

Bob Spitzer was prophetic 4 years ago when he warned that the closed DSM-5 process would lead to a flawed DSM-5 product. He advised the DSM-5 leadership to end its secrecy-- that a lack of openness would inevitably would lead to bad decisions not amenable to self-correction.

I never would have entered the DSM-5 controversy were it not for two of its proposals that risk furthering the already frightening overuse of antipsychotic medication, particularly in children and teenagers.

Martin Whiteley is an MP who represents Perth in the Australian parliament. He has been actively involved in mental health issues and succeeded in a crusade to curb what had been Perth's alarming overdiagnosis and overmedication of Attention Deficit Disorder (ADD).

The British Psychological Society is a highly esteemed organization representing 50,000 members. Recently, it released an open letter to the American Psychiatric Association offering a harshly critical view of DSM-5.

The DSM-5 Scientific Review Group was the last hope for an eleventh hour DSM-5 save. This hope recently died.

DSM-II was published in 1968. DSM-5 will be published in 2013. How much progress have we made? I propose that we approach this question with a quiz.

Humans have just these 2 ways of sorting things--giving them a name or a giving them a number. We have been naming things since the days of Adam.

I just received a very important email from Dr Dayle Jones who chairs the DSM-5 Task Force of the American Counseling Association (ACA). The ACA has provided a much needed wake-up call for the American Psychiatric Association.

The proposal to include "coercive paraphilia" as an official diagnosis in the main body of DSM-5 has been rejected. This sends an important message to everyone involved in approving psychiatric commitment under Sexually Violent Predator (SVP) statutes.

DSM-IV, published in 1994, did not include a cannabis withdrawal disorder diagnosis. DSM-IV-TR clearly stated the reason for the omission: “Symptoms of possible cannabis withdrawal . . . have been described in association with the use of very high doses, but their clinical significance is uncertain.”1

Aside from its reckless proposals for dangerous new diagnoses, the most characteristic thing about DSM-5 has been its remarkably poor planning and its consistently missed deadlines.

The NIMH Research Domain Criteria (RDoC) project raises many questions about DSM-5 and future DSMs.

The thing to remember that there is not a pill for every worry or life problem and that pills can sometimes make things worse.

Writers of diagnostic criteria should consider their work and all its implications. What about adding a new disorder? What might that do to epidemiological capture? Depending on the characteristics of the diagnostic criteria set, many possibilities exist.

In previous blogs and papers, I have done my level best to skewer the misuse of the misdiagnosis "Paraphilia NOS." I regard it as no more than a flimsy justification, concocted to allow the psychiatric incarceration of rapists who would otherwise have to be released from prison to the street.

I was asked three interesting questions by a psychologist with 15 years experience evaluating sexually violent predators. She has testified often--both for the prosecution and for the defense in the hearings that determine the legitimacy of involuntary psychiatric commitment under SVP statutes.

There have been four ringing rejections of the concept of paraphilic rape--in DSM-III, in DSM-IIIR, in DSM-IV, and in a 1999 APA Task Force report. The circumstances surrounding the latter three decisions are fairly well known, the first less so.

In a recent Psychiatric Times blog, Allen Frances engaged a debate with Andrew Hinderliter over the question of change in the diagnostic categories of DSM-5.

One of the impulse-control disorders, Intermittend Explosive Disorder includes serious acts of aggression against person or property that are completely out of proportion to any provocation.

Charles Moser, PhD, MD, has forwarded an interesting suggestion to solve the problem of weak diagnoses that have received a free ride through previous revisions of DSM. His is a middle way intended to steer between the contrasting risks of continuing questionable diagnoses and the risks of eliminating them.

A DSM critic, Andrew Hinderliter sent this perceptive email questioning the wisdom of the most fundamental decision we made in preparing DSM IV-- ie, our goal of keeping the system stable.