1 Boring Old Man

Dr. Allen Frances has done a yeoman’s job of identifying problems in both the process and content of the proposed revision of the Diagnostic and Statistical Manual. But there’s something else about that enterprise that also needs to be added to the mix. Some examples. This is an article for general physicians in the Journal of the American Medical Association. Read it as if you are a Surgeon or an Internist thumbing through the journal:

Why All of Medicine Should Care About DSM-5
^{by Kupfer DJ, Regier DA}
JAMA. 2010 19;303(19):1974-5.

^{The Fifth Edition of Diagnostic and Statistical Manual of Mental Disorders is scheduled for publication in 2013. Although psychiatrists and other mental health care professionals have a high level of interest in this forthcoming edition, other health care professionals should also be interested in the development of DSM-5. For instance, in primary care settings, approximately 30% to 50% of patients have prominent mental health symptoms or identifiable mental disorders, which have significant adverse consequences if left untreated. Even in surgical specialties, many presurgical and postsurgical developments are associated with significant mental health issues. This Commentary is intended to discuss several major goals of the DSM-5 process, which include facilitating further integration of psychiatry into the mainstream of medical practice, facilitating the clinical feasibility of addressing the diagnostic challenges posed by mental disorders in general medical settings, and emphasizing the importance of attending to patients with mental disorders regardless of the clinician’s medical specialty…}

^{How can DSM-5 better address the interface between psychiatry and general medicine?
Two issues receiving attention are the frequent presence of psychiatric symptoms and disorders in patients with other general medical conditions, and the de facto rejection of the primary care version of DSM-IV by general medical practitioners. A study group, implementing a psychiatry and general medical interface, was convened to address these issues. Co-occurrence of psychiatric and general medical symptoms also has implications for the assessment of disability because it is difficult for patients to separate the effects of their physical and mental symptoms on their overall activities of daily living. Accordingly, the DSM-5 disability assessment study group is considering methods to assess disability on a global level. This approach is consistent with that taken by the World Health Organization [WHO]…}

We are appreciative of the thoughtful concerns expressed in the Open Letter about the introduction of new diagnoses, proposals for modifying criteria definitions and thresholds for existing diagnoses. The current draft of the DSM-5 diagnostic criteria, still more than a year away from publication, is continually being refined and reworked by the DSM-5 Task Force and Work Group members. Final decisions about proposed revisions will be made on the basis of field trial data as well as on a full consideration of other issues such as those raised by the signatories to this petition, the 10,000 individuals who responded to the February 2010 and April 2011 postings of draft criteria on DSM5.org, other internal reviews by a Scientific Review Committee, the DSM-5 Task Force, and the APA Board of Trustees. This level of both internal and external review and field trial exposure has never before been undertaken by any previous DSM or ICD revision proposals. We wish to clarify several specific issues you raise. Several disorders that were mentioned, such as Parental Alienation Syndrome, were proposed by outside groups but have not been proposed for inclusion by the Task Force. Some of the newer diagnoses, including Disruptive Mood Dysregulation Disorder (DMDD), Attention Deficit Hyperactivity Disorder (ADHD), Attenuated Psychosis Syndrome Disorder (APSD), Complex Somatic Symptom Disorder (CSDD), Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), and Personality Disorders are all being tested in the 11 large academic field trial centers that have enrolled over 2,000 patients in a rigorous test-retest design to assess the reliability and clinical utility of proposed criteria. Based on the results of these field trials the DSM-5 Task Force and Work Groups will review the criteria for any necessary changes.

The definition of a mental disorder that is contained in DSM-IV is also undergoing a thorough review by the Task Force, which has not adopted the proposed revision that was published by Stein et al. in Psychological Medicine. There is certainly no intent on the part of the DSM-5 Task Force to diminish the importance of environmental and cultural exposure factors as etiological contributors to mental disorders—as indicated by an active study group charged with developing a cultural formulation section as well as culture specific expression issues for individual diagnoses… We wish to express our appreciation to all of the clinicians and research investigators who have invested such intense interest and energy in assuring that the next revision of DSM will be based on the best available clinical experience and research evidence in an effort to improve patient care and our understanding of mental illnesses. We hear your concerns and are aware of those from others in the mental health field, and take them under serious consideration in our deliberations…

It is clearly incumbent on APA to allay the many outstanding concerns raised by the petition with straightforward and credible answers — public relations pablum simply will not cut it. If DSM 5 fails to conduct a serious dialog with its users, there will no reason for them to trust or buy it. Clinicians [and their patients] would be better served by their simply downloading the official ICD-10-CM codes which will be freely available on the internet. The Petition To Reform DSM 5 is the only way to force APA to subject DSM 5 to the independent, external, scientific review that is essential for a safe DSM 5.

But as bad as embarrassing and insulting are, there’s something more. The DSM-5 Task Force isn’t collegial with Psychiatrists either. It’s the American Psychiatric Association, and they talk the same way to Psychiatrists [Setting the Record Straight: A Response to Frances Commentary on DSM-V]. I didn’t quote it here because it’s too long, but this response to one of Dr. Frances’ earlier criticisms is worth reading in full. On this outing, Drs. Kupfer and Regier were joined by Dr. Alan Schatzberg, then president of the APA, so it adds some nasty to the pablum. It sure didn’t work, because Dr. Frances’ output has accelerated since they wrote it.

I expect that sometimes I sound like a psychoanalyst or psychotherapist still mad about the turn of events back in 1980 with the DSM-III. At other times, I may sound like an "anti-neuroscience" guy who wants us all to return to the days when the Oedipus Complex was king. There may still be a dollop of both those things rolling around in there that I don’t know about, though that doesn’t explain why I was silent for thirty years or that I don’t think those things myself. What I do think is that one of the unintended consequences of the changes in those days was that psychiatry was increasingly taken over by people who sold out to the drug companies and jumped on the biological bandwagon without having the scientific discipline or ethics to be there.