DSM

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.

“The proper use of these criteria requires specialized clinical training that provides both a body of knowledge and clinical skills.” How many of us psychiatrists recognize this statement? Or, is it like the fine print that we often gloss over in our everyday contracts and hope it doesn’t cause us trouble at some later time?

After formulating and signing “Melancholia: A Declaration of Independence,” an international cadre of psychiatrists recently launched a campaign to have the upcoming DSM-V recognize melancholia as a distinct syndrome rather than as a specifier for the mood disorders of major depression and bipolar disorder.

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.

Borderline Intellectual Functioning is rarely included in clinical reports and case/treatment team reviews except indirectly when, as part of the mental status examination, mention is sometimes made that the patient’s intellect appears to fall below average limits.

I have elsewhere summarized the problems caused by the excessive and misdirected ambitions of the DSM-V effort.1 My purpose here is to suggest a different, more useful and attainable ambition for DSM-V-namely trying to integrate DSM-V and ICD-11 into one system. If successfully achieved, this would be by far the biggest accomplishment possible in this round of revision.

It used to be that the answer to the above question was: “One . . . but he or she must really want to change.” Now that we are in the DSM process, many other things must be considered. We have watched as the Board assembled the Task Force and Work Groups for almost 2 years, choosing among expertise, years in the field, academic appointments, geographic distribution and freedom from excessive attachments to pharmaceutical and medical device manufacturers, etc, to complete what appears to be a very scientific, secret recipe for “DSM stew.”

>I greatly enjoyed Dr Ron Pies’ editorial “What Should Count as a Mental Disorder in DSM-V?”1 in which he encouraged framers of DSM-V to critically examine the boundaries of mental illness and to more carefully distinguish between diseases, disorders, and syndromes. As I have noted elsewhere, current plans to integrate a “spectrum” approach into DSM-V require a careful consideration of these issues that must be defensible to critics of diagnostic expansion within psychiatry.2

There is no magic moment when it becomes clear that the world needs a new edition of the DSM. With just one exception, the publication dates of all previous DSM’s were determined by the appearance of new revisions of the International Classification of Diseases (ICD). Thus, DSM-I appeared in conjunction with ICD-6 in 1952; DSM-II with ICD-8 in 1968; DSM-III with ICD-9 in 1980; and DSM-IV with ICD-10 in 1994. The lone exception was DSM-IIII-R, which appeared in 1987-out of cycle only because it was originally meant to be no more than a minor revision. The official publication date for DSM-V is May 2012. That date was picked to be consistent with an earlier, no longer correct, expectation that ICD-11 would be published in that same year.

I found the American Psychiatric Association’s response (“Setting the Record Straight”) to the commentary by Allen Frances, MD, (“A Warning Sign on the Road to DSM-V”) outlining concerns about the DSM-V to be an embarrassing black mark against the association.* As president of an organization supposedly devoted to scientific objectivity, Dr Alan Schatzberg’s (lead author of the response) ad hominem attack and use of unprovable innuendos to discredit Dr Frances reflects an approach I want nothing to do with.

I read with great interest and considerable apprehension Dr. Frances’ assessment of the DSM-V developmental process ("A Warning Sign on the Road to DSM-V," Psychiatric Times, July 2009).

I had intended not to reply to the silly suggestion made by the APA leadership that I wrote my critique of the DSM-V process out of financial motivations.

I appreciate Drs Spitzer and Frances’ prompt response to my article, which was published in the July issue of Psychiatric Times. I also thank them for their good wishes and thoughts about what we are doing as members of the DSM-V workgroups-membership whose rules we all knew and freely accepted.