pilot error…

Posted on Saturday 22 September 2012

DSM-5 Heads to the Finish Line
Clinical Psychiatric News
September 20, 2012

The long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM-5, is set to be published next May, but critics continue to warn that the current proposals could lead to widespread misdiagnosis and a potential increase in the use of drug therapies. The new manual takes a "developmental approach" to diagnosis, emphasizing the full lifespan of the patient, said Dr. David J. Kupfer, chair of the DSM-5 Task Force and a professor of psychiatry at the University of Pittsburgh. "That automatically invokes an earlier concern about diagnosis," he said. "It automatically invokes the issue of what are some of the risk factors." It’s that push for the early identification of mental illness that has some clinicians concerned…

In 1980, Dr. Spitzer’s DSM-III would be an atheoretical, descriptive manual based on reliability – aiming towards the goal that different evaluators would be able to independently reach the same diagnostic conclusion in a given patient. While there was a background agenda to quash psychoanalytic or other psychological constructs and a leaning towards biological explanations, he was, by and large, able to keep theory out of the classification itself. There was an exception. In his zeal to put an end to the idea that many people are clinically depressed because of things in their life and mind, he lumped all depression into one large category.  Big error, big consequences, but who’s counting? Beyond that, the manual was still more than a classification, it was a way of thinking about mental illness and psychiatry itself. As a result, the concept of the mind·brain dichotomy faded into extinction, at least in psychiatry. Subsequent revisions [DSM-IIIR, DSM-IV, DSM-IVTR] followed Spitzer’s atheoretical lead. However, as we all know, psychiatry itself became focused increasingly on biology, though in an unusual way. While there was much talk and research about neuroscience and neuroanatomy in various psychopathological conditions, the overwhelming central preoccupation of the specialty has been on the biology of treatment – primarily using medications to manipulate the biochemical milieu of the neuronal synapse.


Biomarkers: From the outset, the DSM-5 was going to break with Spitzer’s atheoretical meme and put psychiatric diagnosis on a firm biological footing. Neuroscience research is largely organized by technologies: neurotransmitter/receptor metabolism measures; neuroimaging, particularly fMRI scans with blood-oxygen-level-dependent [BOLD] contrast; genetic mapping; traditional neuroendocrine studies; etc. And while much has been done with these tools, the postulated biological basis for mental illness and classification remains in the realm of the speculative and undiscovered. It will not be the DSM-5 they hoped for. No biomarkers to report.

Early Detection: And when Dr. Kupfer says, "‘developmental approach’ to diagnosis, emphasizing the full lifespan of the patient" he’s mainly referring to the preventive medicine concept of early detection and early intervention. In the first part of the decade, there was a growing interest in Dr. Biederman’s concept of the bipolar child, pushing a major adult illness back into childhood. But that idea has fallen out of favor, and the transition into adult bipolar illness remains unproven if even still in the running. Likewise, Dr, McGorry’s group in Australia has attempted to characterize a pre-Schizophrenic clinical diagnosis generating a high level of excitement and interest, but so far that hasn’t panned out either. It was a controversial piece of the DSM-5 Task Force’s deliberations as the Attenuated Psychosis Syndrome, but it didn’t "make the cut" against stiff opposition and poor results. So, like the missing biomarkers, the concrete representations of the ‘developmental approach’ also seemed to evaporate.

Biological Basis of Mental Illness: While the focus of psychiatry has been biological, the descriptive atheoretical DSM was well suited to other specialties involved in the treatment mental illness – psychology, social work, counselors, etc. The DSM-5, however, committed to the neuroscientific bent of most psychiatrists in high places – hardly atheoretical. So even with the failure to find biosignatures or define premonitory syndromes of adult illness, the DSM-5 is unmistakably biological, even proposing to change the definition of mental illness to "a behavioral or psychological syndrome that reflects an underlying psychobiological dysfunction" – a definition that is unproven, self-serving, and mostly incorrect. One can only wonder, "What were they thinking?" And even if they back off from that definition, the damage is done. As they say in games, "A card laid is a card played." We know what they’re thinking.

The Revision: The DSM-IV had some areas that badly needed practical revision – Autism, ADHD, Major Depressive Disorder – the latter being the most blatantly in need. In the DSM-5 Revision, it was essentially untouched except to make it even less useful by adding grief to the already hopelessly over-inclusive category [removing the last vestige of common sense from the class]. And they were so busy doing other things, trying to do something new, that they ignored the basic task of revision.

The Field Tests: As if driven to self destruction, they cancelled one of two scheduled sets of Field Tests and put all their eggs in one basket – then they dropped it. The Field Tests were a disaster, taking away the one concrete measure of their work – reliability, the bedrock justification for the existence of the DSM in the first place. And to compound the damage, they’ve kept the results largely to themselves. They’ve added un-reliable to non-atheoretical.

A Fundamental Flaw: They’re now dead-set on making the same mistake that has had such a profoundly negative effect on psychiatry over the last three decades. They’re following the lead of the pharmaceutical industry when they have a failed clinical trial . After spending a lot of time and money developing a psychopharmaceutical agent, the pharmaceutical company does some clinical trials. If the trials come out with less than stellar results, they have so much invested in the enterprise that they doll them up and publish them anyway – often claiming success – or they hide the negative results. They just can’t say, "You win some, and you lose some". Both the expectations and potential loss are too great. The DSM-5 Task Force is doing the same thing. They can’t hide their failures, even though they tried to put up a firewall. We can thank their predecessors, Dr. Robert Spitzer and Dr. Allen Frances, for showing us that part of the story, mainly the latter. Robert Spitzer focused a microscope on the DSM-5’s secrecy, and Allen Frances kept us abreast of what he saw when he looked through the scope’s eyepiece – it wasn’t at all pretty.

I’ve only made it through one paragraph of this article in the Clinical Psychiatric News. There’s plenty more, and I’d suggest a thorough read. While my head is filled with thoughts about what all of this will mean for the long haul, I’m going to uncharacteristically let those thoughts incubate and stick to the question on the table. They had a rhetoric in place to go with their planned outcome. That outcome failed to materialize, yet the rhetoric persists. No matter what happens with the DSM-5 when it’s published, it is a simply a failed enterprise – it crashed. Pilot error…


hat tip to Suzy Chapman 

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