DSM

We have already gone past the midway point of the time allotted for the preparation of DSM-V. I realized that not enough has been accomplished and that most of what is being suggested is headed in a very wrong direction. Particularly troubling is the almost total lack of recognition that changes in an official manual of diagnosis can have devastating unintended consequences. Before it is too late, I feel a responsibility to help DSM-V avoid mistakes by sharing the lessons learned during the past 30 years working on the 3 previous revisions of the DSM. Perhaps my comments may help the DSM-V Task Force avoid some of the hidden landmines I think they are dancing around.

We should begin with full disclosure. As head of the DSM-IV Task Force, I established strict guidelines to ensure that changes from DSM-III-R to DSM-IV would be few and well supported by empirical data. Please keep this history in mind as you read my numerous criticisms of the current DSM-V process. It is reasonable for you to wonder whether I have an inherently conservative bias or am protecting my own DSM-IV baby. I feel sure that I am identifying grave problems in the DSM-V goals, methods, and products, but it is for the reader to judge my objectivity.

In “Changes in Psychiatric Diagnosis” (Psychiatric Times, November 2008, page 14) Michael First relates the sad fact that the reorganization of DSM is still without formal guidelines and continues to be subject to the vicissitudes of groupthink and vocal constituencies. He relates that he and Allen Frances envisioned the application of biologically based diagnostic criteria when summarizing the work of DSM-IV, but complains that no criteria are forthcoming as yet.

The polemics between Drs Pies and Wakefield and Horwitz (“An Epidemic of Depression,” Psychiatric Times, November 2008, page 44) have validity, but their commentaries did not touch on the real bone of contention. Dr Pies does not believe that just because psychosocial precipitators of a depression-specifically, bereavement-are known, somehow the significance of the depression should be viewed differently.

What exactly is a “mental disorder”? For that matter, what criteria should determine whether any condition is a “disease” or a “disorder”?

In their response to the commentary by Drs Lisa Cosgrove and Harold Bursztajn in the January 2009 issue of Psychiatric Times (“Toward Credible Conflict of Interest Policies in Clinical Psychiatry,” page 40), David Kupfer and Darrel Regier, the chair and vice-chair, respectively, of the DSM-V Task Force, invite readers to “monitor the most inclusive and transparent developmental process in the 60-year history of DSM at our www.dsm5.org Web site.”

A recent letter to the American Psychiatric Association (APA) from Sen Chuck Grassley about the APA’s financial relationship with pharmaceutical companies raises concerns about undue industry influence.1 By instituting a disclosure policy for DSM-V, the APA took a halting first step in restoring public trust in the most influential text on psychiatric taxonomy in the world. Unfortunately, the APA’s efforts at creating a conflict of interest (COI) policy have failed to ensure that the process for revising diagnostic and therapeutic guidelines is one that the public can trust. The need for more safeguards was evidenced when the APA reported that of the 27 task force members of DSM-V, only 8 reported no industry relationships.2 The fact that 70% of the task force members have reported direct industry ties-an increase of almost 14% over the percentage of DSM-IV task force members who had industy ties-shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed.

After some members and mental health writers criticized the American Psychiatric Association (APA) for “secrecy” surrounding the development of DSM-V, the Board of Trustees of the APA voted to make public regular DSM-V reports as well as summaries from work group chairs on the Web site at www.dsm5.org.

Suppose your new patient, Mr. Jones, tells you he is feeling “really down.” He meets all DSMIV symptomatic and duration criteria for a major depressive episode (MDE) after having lost his wife to cancer 2 weeks ago. Should you diagnose major depressive disorder?

The Psychodynamic Diagnostic Manual1 (PDM) was created by a task force chaired by child psychiatrist Stanley Greenspan, MD, in cooperation with the American Psychoanalytic Association, the International Psychoanalytical Association, the Division of Psychoanalysis of the American Psychological Association, the American Academy of Psychoanalysis and Dynamic Psychiatry, and the National Membership Committee on Psychoanalysis in Clinical Social Work.

Sexual dysfunctions as distinct syndromes were first identified in DSM-III in 1980. At that time, sets of criteria were specified for inhibited sexual desire, inhibited sexual excitement, inhibited female orgasm, inhibited male orgasm, premature ejaculation, dyspareunia, and functional vaginismus.

Of all the misconceived DSM-5 suggestions, the one touching the rawest public nerve is the proposed medicalization of normal grief into a mental disorder. Fierce opposition has provoked two editorials in Lancet, a front page New York Times story, and incredulous articles in more than 100 journals around the world.

A discussion of the intellectual, social, and historical similarities and differences between sacred texts and the DSM would require a full-length book, but we will concentrate here on 5 main aspects: controversy, communication, interpretation, change, and power.

With expansion of the concept of bipolar disorder (BD), there has been concern about the potential for overdiagnosis. However, diagnostic errors in bipolar disorder are currently skewed towards underdiagnosis.

Proposed changes in the conceptualization of compulsivity and impulsivity in the DSM-V will have important implications in the way clinicians recognize and treat these disabling conditions.

The DSM may be flawed, but it is the best available system for organizing and diagnosing mental disorders, and it remains a model for other medical specialties.

Decades of labor have been poured into the formulation of the DSM and its descendants. Is this system of classification still useful and relevant to clinical practice? Should psychiatrists continue to revise it or get rid of it altogether?

The issue for us is whether positive thinking is relevant in certain situations. Would it help, or would it create more problems than it would solve?

Methods for detecting possible abuse and how to help victims (even if they are unable to help themselves or leave their abuser).

Psychopathy (renamed antisocial personality disorder) is marked by persistent violations of social norms, including lying, stealing, truancy, inconsistent work behavior and traffic arrests.