DSM

Time is running out on DSM5 and the mistakes keep piling up. The latest puzzling misstep is the design for the DSM5 field trials. The APA will conduct a remarkably complex and expensive reliability study to determine whether 2 raters can agree on a diagnosis. It will devote enormous resources to answer a question that once mattered greatly but is now of quite limited interest. Meanwhile, DSM5 will perversely avoid the one question that does really count: ie, what will be its likely impact on the rates of psychiatric diagnosis? At least $2.5 million and 1 year later (or possibly 2, if things get delayed as I expect they will), DSM5 will still be flying completely blind on the safety of its proposals.

DSM5 first went wrong because of excessive ambition; then stayed wrong because of its disorganized methods and its lack of caution. Its excessive and elusive ambition was to aim at a “paradigm shift.” Work groups were instructed to think creatively, that everything was on the table. Accordingly, and not surprisingly, they came up with numerous pet suggestions that had in common a wide expansion of the diagnostic system-stretching the ever elastic concept of mental disorder. Their combined suggestions would redefine tens of millions of people who previously were considered normal and hundreds of thousands who were previously considered criminal or delinquent.

The recently posted criteria sets for DSM5 are a mess. The writing is unclear, inconsistent, and imprecise. Unless they are edited and drastically improved, any field testing based on them will be a waste of time, effort, and money- and DSM5 may not be usable.

Nine months ago, Dr. Robert Spitzer and I wrote to alert you that DSM5 had gone badly off track. We warned that its process was unsupervised, poorly planned, secretive, disorganized, and was falling far behind schedule. You took the appropriate steps of appointing an Oversight Committee and delaying for 1 year the target dates for field trials and for the publication of DSM5.

I often get asked if practical consequences should play an important role in DSM5 decisions. It was posed again yesterday in response to my blog "Bipolar II Revisited" which tangentially raised the issue.

The recently posted first draft of DSM-5 has suggested a whole new category of mental disorders called the "Behavioral Addictions." The category would begin life in DSM-5 nested alongside the substance addictions and it would start with just one disorder (gambling).

Sometimes you spot a serious problem and figure out a very well-intended solution, only to discover eventually that your solution created as much trouble as the original problem. The workers on DSM5 have spotted an enormously worrying problem-the wild overdiagnosis of childhood bipolar disorder (BD) which has led to a massive increase in the use of antipsychotic and mood stabilizing medications in children and teenagers.

DSM5 suggests 2 changes that would make it much easier for an adult to get a first time diagnosis of Attention Deficit Disorder (ADD): 1) reducing the number of symptoms required for adults from 6 to 3; and 2) relaxing the requirement that the onset of symptoms must have occurred before age 7 (by allowing the onset to be up to age 12).

The first drafts of DSM5 were posted 2 months ago, allowing the field and the public a first glimpse into what had previously been an inexplicably secretive process. Today is the last day for public comment on these drafts. This is a plea for continued openness and iterative interchange in the next steps in the preparation of DSM5.

DSM5 first went wrong because of excessive ambition; then stayed wrong because of its disorganized methods and its lack of caution. Its excessive and elusive ambition was to aim at a "paradigm shift.”

Avoid Surprises and Unintended Consequences

DSM-IV provides separate categories for Substance Abuse and Substance Dependence. The typical substance abuser is someone who gets into recurrent, but intermittent, trouble as a consequence of recreational binges. This is in contrast to the continuous and compulsive pattern of use that is typical of DSM-IV Substance Dependence.

There are 2 very different methods of describing people with a mental health problem. A typical psychiatrist will give the mental disorder a name. Many psychologists would prefer to give it a number on a rating scale. The first “categorical” approach is the simplest and most natural way people sort things. It is the method used throughout medicine (with just a few exceptions like hypertension). The second “dimensional” approach works best to describe phenomena that are continuous, lacking in clear boundaries, and reducible to numerical measurement.

The proposal for a "Psychosis Risk Syndrome" aims to solve a pressing problem in psychiatry-- the need for early identification and preventive treatment.

I have been closely following the discussions of the proposed DSM5 in Psychiatric Times. Your publication of this discourse is a significant contribution to our field. As a research psychiatrist who has published over 150 peer-reviewed papers, I strongly support Allen Frances’ emphasis on the importance of continuity in diagnostic criteria for DSM5.

A major general problem in the preparation of DSM5 is that the various Work Groups have been given far too little guidance and support. This explains why: 1)most of the criteria sets are written so obscurely and inconsistently; 2) the rationales for change vary so widely in depth and quality across Work Groups,and; 3) so many suggestions that should have no chance at all have made it this far without being tossed.

The recently posted draft of DSM5 makes a seemingly small suggestion that would profoundly impact how grief is handled by psychiatry. It would allow the diagnosis of Major Depression even if the person is grieving immediately after the loss of a loved one. Many people now considered to be experiencing a variation of normal grief would instead get a mental disorder label.

Posted on February 3, I asked the question, CAUTION! Who Should Be the DSM5 Diagnostician? I suggested that we needed to pay as much attention to who would be designated as the diagnostician as on the revised diagnostic criteria.

Quick-which screening test or instrument has greater specificity for the target condition: the PSA (prostate specific antigen) test for prostate cancer, or the BSDS (Bipolar Spectrum Diagnostic Scale), for bipolar disorders?

Allen Frances, MD, identifies a number of concerns about the draft DSM5 revisions.1 Not mentioned in his commentary, but of significant concern, is a proposal that might subsume tic disorders under a new category called “Anxiety and Obsessive-Compulsive Disorders.”

In his recent David Letterman-like Top-19 list of DSM5 issues, Dr Allen Frances targeted a proposed revision of the DSM-IV diagnosis of Pedophilia, and 2 proposed new diagnoses: Hypersexual Disorder and Paraphilic Coercive Disorder.

Another lifetime ago-just after leaving residency-I took a job as a psychiatric consultant at a large, university mental health center. Had I known the poisoned politics of the place, I would have headed for someplace safe-like, say, Afghanistan.

In his recent blog posting, Dr Steven Moffic proposed that only psychiatrists be allowed to certify DSM diagnoses. While I disagree, I commend Dr Moffic for raising this controversial topic, which inevitably brings up a number of basic issues challenging our profession.

“The exclusion of symptoms judged better accounted for by Bereavement is removed because evidence does not support separation [or] loss of loved one from other stressors.”1

Unless you have been living on a desert island for the past 2 years, you are well aware that the development of DSM-V is well under way.