and will..

Posted on Sunday 3 June 2012

The DSM-5 Web Site now links to DSM-5 Facts, a site prepared for them by a Public Relations Firm, GYMR. Last week, the Huffington Post had an article in response to Dr. Allen Frances’ criticism, DSM-5 Inaccuracies: Setting the Record Straight, by by James Scully, APA Medical Director, that began,
In his Huffington Post blog dated May 30, 2012 titled "DSM-5 Costs $25 Million, Putting APA in a Financial Hole," Allen Frances, M.D., demonstrates either an embarrassing lack of knowledge and understanding of financial reporting or an intentional misrepresentation of facts in his continuing effort to attack the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is published by the American Psychiatric Association…
Meanwhile, the results of the Field Trials have not been posted, though there are only 12 days to go before they again close the public comments. Dr. Scully’s retort is little different from the response to Dr. Frances’ original warning about the DSM-5 process back in 2009, Setting the Record Straight: A Response to Frances Commentary on DSM-V By Alan F. Schatzberg, James H. Scully, David J. Kupfer, and Darrel A. Regier. In both cases, the response makes ad hominem comments about Dr. Frances and reiterates the expertise of the DSM-5 Group.

Here’s my compilation of the Kappa values from the Field Trials for review::

Disorder   DSM-5 (95% CI)     DSM-IV     ICD-10     DSM-III  

Major neurocognitive disorder .78 (.68 – .87) .66 .91
Autism spectrum disorder .69 (.58 – .80) .85 .77 -.01
Post traumatic stress disorder .67 (.59 – .74) .59 .76 .55
Child attention deficit disorder .61 (.51 – .72) .59 .85 .50
Complex somatic disorder .60 (.41 – .78) .45* .42*
Bipolar disorder .54 (.43 – .65) .69
Oppositional defiant disorder .41 (.21 – .61) .55 .66
Major Depressive Disorder (in adults) .32 (.24 – .40) .59 .53 .80
Generalized anxiety disorder .20 (.02 – .36) .65 .30 .72
Disruptive mood dysregulation disorder .50 (.32 – .66)
Schizophrenia .46 .76 .79 .81
Mild neurocognitive disorder .50 ( .40 – .60)
Schizoaffective Disorder .50 .54 .51 .54
Mild traumatic brain injury .46 (.28 – .63)
Alcohol use disorder .40 (.27 – .54) .71 .80
Hoarding .59 (.17 – .83)
Binge Eating .56 (.32 – .78)
Major Depressive Disorder (in kids) .29 (.15 – .42)
Borderline personality disorder .58 (.46 – .71)
Mixed anxiety/depressive disorder .06
Conduct Disorder .48 .57 .78 .61
Antisocial Personality Disorder .22
Obsessive Compulsive Disorder .31
Attenuated Psychosis Syndrome .46 (0-?)

It’s a little hard to imagine that the APA is actually planning to proceed with a May 2013 publication date with those values staring us all in the face. The whole rationale for the DSM-III hinged on reliability [kappa]. The failure to achieve reliability in the most basic of diagnoses isn’t about Dr. Frances or the DSM-5 Task Force’s expertise. It’s an overall grade on the DSM-5 product and their implementation process.

Admitting failure is a hard thing to do, but it’s their only recourse. Otherwise, we’ll have to admit it for them. And will…
  1.  
    Nick Stuart
    June 3, 2012 | 10:28 AM
     

    I just cannot understand the lack of the idea, that if the kappa results are worse than the DSM III for example, why do they not just reprint that edition? Is this madness or insanity? Btw did you work out what the figures in brackets means? Ta.

  2.  
    Tom
    June 3, 2012 | 6:45 PM
     

    Those are called “confidence intervals.” For example, in the case of “major neurocognitive disorder” there is a 95% chance that the “true” kappa value falls in the range of .68 and .87.

  3.  
    Stan
    June 3, 2012 | 7:13 PM
     

    It’s safe bet DSM5 will be published without any further delay….psychiatry’s industrial life & professional heartbeat are banking on it….doesn’t matter if it’s junk science, and does more harm than good…It is now all about those huge inflated ego’s & blood money…

  4.  
    June 4, 2012 | 3:57 PM
     

    In pondering the platform of new APA President Jeffrey Lieberman, it seems he sees no issues except to get the DSM-5 out on time http://www.liebermanforapa.com/issues/index.html (What the heck is the election process anyway? What percentage of APA members vote?)

    And, oh, yeah, ginning up the public relations machine. So many of psychiatry’s leaders think psychiatry is losing prestige because of unfair press! It’s only a matter of getting the right p.r. out there….

    Note that improving outcomes and patient safety is nowhere on Lieberman’s radar. To my mind, this is what would improve psychiatry’s reputation, but I guess its leaders think its success is satisfactory.

    My suspicion is, consequently, flaws in the DSM-5 are immaterial. Accurate, reliable diagnosis is not important. Maybe those vast sums spent on DSM-5 development went to expensive dinners and meetings at resorts. In the corporate world, that’s often how big but useless initiatives are carried out.

  5.  
    June 4, 2012 | 6:43 PM
     

    Psychiatry has become a hegemonic force having more power than it’s due. Too bad it isn’t more more empirical.

  6.  
    June 5, 2012 | 1:02 PM
     

    There are now just ten days left before this third and final comment period closes. If the Task Force does not get a report out soon, stakeholders have no choice but submit feedback without the benefit of data from the trials to inform their submissions.

    This is particularly important for those sections of DSM-IV where substantial changes are being proposed, for example, Somatic Symptom Disorder (SSD) – a brand new diagnostic category for which there is no published research on epidemiology, clinical characteristics or treatment.

    It is evident from the “Rationale/Validity” PDF document published with last year’s draft that the Work Group was unclear what effect its proposals for radical redefining of the existing “Somatoform Disorders” would have on prevalence rates. When discussing the SSD “B type” criteria (which Joel Dimsdale admits his group has struggled with from the outset) the document had no data on prevalence estimates and no data on impact of different thresholds for the “B type” criteria – just a bunch of “XXXXXs.”

    A year later, there are still no published findings.

    How can APA claim this has been a transparent process with a high level of professional and consumer consultation when it fails to place its findings in the public domain? In the absence of professional and public scrutiny of field trial results and with no substantial body of independent evidence to support the group’s proposals, one hopes the Scientific Review Committee will be looking particularly hard at the impact on prevalence rates and implications for all illness groups of this proposed new SSD category, which will allow a “bolt-on” Dx of a mental health disorder for all illnesses if the clinician considers the patient also meets the criteria for SSD.

    Given the delay in publishing data from the field trials, APA needs to get its report out now and extend the review period by at least a further two weeks to the end of June.

  7.  
    Tom
    June 5, 2012 | 8:00 PM
     

    RE: Conversion Disorder (Functional Neurological Symptom Disorder)

    They have now removed the criterion that a psychological/psychosocial stressor or stressors is or are related to the onset of the condition. That’s plain stupid. More evidence for a DSM-5 agenda to remove psychology or the “mind” from psychiatry and our understanding of mental illness.

  8.  
    June 6, 2012 | 8:45 AM
     

    Extract from the J 02 Conversion Disorder (FNSD) Rationale that relates to removal of the previous criterion B:

    http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=8#

    J 02 Conversion Disorder (Functional Neurological Symptom Disorder)

    Rationale Tab

    [...]

    Removal of previous criterion B. “Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors” We propose that this criterion be eliminated and discussion of etiologic factors placed in accompanying text. This DSM IV criterion reduces the utility and reliability of the diagnosis in practice because:

    (a) It confounds clinical description with a proposed but unproven etiology.
    (b) The research evidence indicates that observed psychological factors are often non-specific; that is, they occur in patients with other conditions, often with a similar frequency; this non-specificity makes a judgment of their relevance in an individual case of ‘conversion’ subjective and potentially unreliable.
    (c) In a substantial proportion of apparent cases of conversion – as defined by neurological symptoms not explained by disease – psychological factors cannot be convincingly or reliably demonstrated.

  9.  
    June 6, 2012 | 9:53 AM
     

    There are considerable concerns about subjectivity and potential unreliability of the B type criteria for Complex Somatic Symptom Disorder (CSSD), now proposed to drop the “Complex” term for this third draft in favour of “Somatic Symptom Disorder” (SSD).

    For this third draft, the requirement to meet the criteria for SSD has been lowered from “at least two” from the B type criteria to “at least one” from the B type criteria.

    http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=368

    [...]

    B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least one of the following must be present.

    (1) Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
    (2) Persistently high level of anxiety about health or symptoms
    (3) Excessive time and energy devoted to these symptoms or health concerns

    In the DSM-5 field trials, 15% of the “diagnosed illness” study group (cancer and malignancy plus severe coronary disease patients) met CSSD criteria when one of the B type criteria was required; if the threshold was increased to two B type criteria about 10% met criteria for diagnosed illness + Somatic Symptom Disorder.

    For the 94 “functional somatic” study group (irritable bowel and “chronic widespread pain”), about 26% were coded when one B type cognition was required; 13% coded with two B type cognitions required.

    This new SSD category “…will allow a diagnosis of somatic symptom disorder in addition to a general medical condition, whether the latter is a well-recognized organic disease or a functional somatic syndrome…”

    “…These disorders typically present first in non-psychiatric settings and somatic symptom disorders can accompany diverse general medical as well as psychiatric diagnoses. Having somatic symptoms of unclear etiology is not in itself sufficient to make this diagnosis. Some patients, for instance with irritable bowel syndrome or fibromyalgia would not necessarily qualify for a somatic symptom disorder diagnosis. Conversely, having somatic symptoms of an established disorder (e.g. diabetes) does not exclude these diagnoses if the criteria are otherwise met…”

    Has the SSD Work Group produced prevalence estimates for the potential increase in mental health diagnoses across the entire disease landscape and might we anticipate this data when “full results” of the field trials eventually emerge?

    In the absence of a body of independent evidence on the reliability and validity of SSD as a construct and on the potential implications for patients of a diagnosis of diabetes + SSD, cancer + SSD, angina + SSD, IBS + SSD etc, how can the Task Force justify pressing on with these proposals and why there has not been more scrutiny of this proposed new disorder and its implications by mental health and non mental health clinicians and allied professionals?

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