DSM

In my previous blog, The Missing Person in the DSM, I questioned whether the DSM diagnostic manual classifies psychiatric disorders or the individuals suffering from diagnostic disorders-Ms Smith’s bipolar disorder, or Ms Smith, a person with bipolar disorder.

A large new study from Australia found that DSM-5 would cause a sky-rocketing 60% increase in the rate of alcohol use disorders.

Gary Greenberg, PhD is a psychotherapist, author, teacher, and historian of psychiatric diagnosis. His writings are characterized by penetrating insight, elegant wordsmithing, entertaining story telling, and a dig-deep, no-holds-barred search for underlying meaning.

There have been three positive developments. The rest of the DSM-5 news continues to be extremely worrisome, and time is running out.

Last week, I had a brief, but heated debate with a friend who is on the DSM-5 Task Force. He is strongly supporting a proposed new diagnosis for DSM-5 that I oppose just as strongly.

The New York Times of Dec 20,2010 carried an alarming story. It seems that during the past decade, college students have suddenly become much more mentally ill.

Recently, the Substance Use Disorder Work group of the DSM-5 announced the inclusion of “craving” in the diagnostic criteria for all substance use disorders despite its lack of empirical support from the very analyses conducted by that Workgroup. In addition, no detailed literature review supports the decision to make “craving” a core symptom of Substance Use Disorder syndromes.

Many people associated with DSM-5 have privately expressed their serious doubts to me, but felt muzzled into public silence by constraining confidentiality agreements and loyalty to the process.

Here’s a question. As you sit across from your patient, what or whom are you treating: Ms Smith’s bipolar illness, or Ms Smith, a person with bipolar illness? The DSM leans toward the first choice.

We are delighted that you have appointed a DSM-5 Scientific Review Work Group and charged it with assessing the quality of evidence supporting the DSM 5 proposals.This is great news, probably the last hope to weed out proposals that could do great harm to the Association, our field, and to our patients.

The doctor’s role is to go beyond the obvious and to detect subtle determinants. Good diagnosticians have been trained to look beneath the loud symptom and consider underlying factors.

These issues-among others-raise this question: Is the addition of a new diagnosis such as TDD to DSM-5 the best way to manage the issue of classification of youths with chronic, severe irritability and potential misdiagnosis of bipolar disorder?

As I was driving to work on February 10, 2010, I listened to the National Public Radio host Melissa Block talking about how children labeled “bipolar” may get a new diagnosis. I was shocked that the chair of one of the DSM5 work groups, David Shaffer, MD, would discuss a controversial diagnostic topic with the media.

The ideal field test would study how the diagnostic manual will eventually perform under conditions most closely approximating its future everyday use. The goal is to avoid unpleasant surprises in translation from what has been written on paper to what is practiced in real life. No field test can ever approach the ideal.

Eventually, DSM-5 will be a rushed patch-work. The only hope for a usable DSM-5 is for the Trustees to exert their authority to correct an errant process. But they will act only if there is mounting outside pressure and widespread public concern.

The DSM does and must involve both science and pragmatism. It must use the science that is available, but it must also make countless judgment calls that are not grounded in solid empirical evidence-and surely it makes sense to consider practical consequences in doing the latter.

The project culminating in the 2 issues of the Bulletin of the Association for the Advancement of Philosophy and Psychiatry (the Bulletin) included in PDF format with this introduction has its own history.

This essay does not proffer a change in the classification of specific conditions but will sketch a new meta-concept of evaluative disorders that encompasses a number of prevalent and serious psychiatric diagnoses.

In a recent issue of Psychiatric News, members of the DSM-5 Task Force reported on the dimensional measures being considered for DSM-5. These take 2 forms: severity scales for individual disorders, and “cross-cutting” measures that cut across disorders. For this brief piece, I will focus on the latter, the more interesting and controversial of the proposed dimensions.

Designers of descriptive diagnostic criteria for mental disorders face some of the same problems as fishermen. Fishermen, like nosologists, want to capture not just any fish but a particular kind. Fishermen deal with this problem in various ways.

In his ongoing critique of the DSM-5 process, Dr Allen Frances started a brushfire recently in challenging the DSM-5 Mood Disorders Work Group proposal to remove the bereavement exclusion from the diagnostic criteria for a major depressive episode. Here’s a summary of the debate.

The DSM-5 Work Group that first suggested the inclusion of “Psychosis Risk Syndrome” has halfway come to its senses. It has dropped this stigmatizing name in a last ditch repackaging effort to salvage the proposal.

Are psychiatrists agents of the police or doctors who care for the sick? Thomas Szasz raised this question 50 years ago in his iconic “The Myth of Mental Illness.” Psychiatry has changed in the ensuing decades, but Szasz’ question is still relevant. Why?

Although Charles O’Brien, MD, who heads the substance-related disorders work group, is a vigorous proponent of the notion of addiction as a disease, nothing about the proposed DSM-5 substance-related disorders section supports the idea that the syndrome is best understood as a chronic brain disease.

Before jumping the gun to a premature and potentially harmful diagnosis, why not watchfully wait a few more weeks to determine if the grief is severe and enduring enough to warrant the label of mental disorder.

Any effort to develop a diagnostic manual for world-wide use must grapple with the question of cross-cultural applicability. The description and diagnostic criteria for schizophrenia must work as well in East Timor as in the US or France. In this piece I choose PTSD to show the complexity of the cultural issue for DSM-5.

The furor surrounding the recently proposed Alzheimer's Guidelines was provoked by their premature attempt to introduce early diagnosis, well before accurate tools are available. The same laudable, but currently clearly unrealistic ambition has propelled two of the worst suggestions for new diagnoses in DSM-5: Psychosis Risk and Mild Neurocognitive.

In an earlier posting, I considered the merits and flaws of the DSM-5 online website. For this posting, I consider the significance and implications of a cyber-DSM.

Dr Muller, in his piece “Psychiatric Symptoms Can be Understood Even When These Symptoms Cannot Be Explained,” makes a number of assertions about DSM-III and its successors that reflect a mischaracterization of its “descriptive approach.”

Since the early twentieth century, when Alois Alzheimer and Emil Kraepelin constructed it as a unified clinical-pathological entity, Alzheimer’s disease has been both one of the most stable and one of the most problematic neuropsychiatric entities.