Posted on Saturday 29 December 2012

Back in 2002, I wasn’t paying any attention to DSM-5 DSM-V, so I missed their opening gambit. The DSM-III of 1980 was unique in that it was the vehicle for a changes that went far beyond the assigned task. Apparently, the DSM-5 Task Force wanted to make a similar leap. Whereas the DSM-III moved us to a non-committal position on causality, the DSM-5 was going to reverse that position and move us to a solid biological foundation:
    In the ongoing quest to improve our psychiatric diagnostic system, we are now searching for new approaches to understanding the etiological and pathophysiological mechanisms that can improve the validity of our diagnoses and the consequent power of our preventive and treatment interventions venturing beyond the current DSM paradigm and DSM-IV framework. This thought-provoking volume produced as a partnership between the American Psychiatric Association, the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse represents a far-reaching attempt to stimulate research and discussion in the field in preparation for the eventual start of the DSM-V process, still several years hence. The book:

    • Explores a variety of basic nomenclature issues, including the desirability of rating the quality and quantity of information available to support the different disorders in the DSM in order to indicate the disparity of empirical support across the diagnostic system.
    • Offers a neuroscience research agenda to guide development of a pathophysiologically based classification for DSM-V, which reviews genetic, brain imaging, postmortem, and animal model research and includes strategic insights for a new research agenda.
    • Presents highlights of recent progress in developmental neuroscience, genetics, psychology, psychopathology, and epidemiology, using a bioecological perspective to focus on the first two decades of life, when rapid changes in behavior, emotion and cognition occur…
Put simply, they were sure that they knew where their neuroscience was headed and planned an agenda to get us there [guess they hadn’t heard that the past is history, the future’s a mystery, the present’s the gift]. Thomas Szasz once called their kind of thinking something like, "psychiatry’s endless promissory note." That’s too cynical for my tastes, but I do get his point. I call it future-think. But whatever it’s called, it’s the idea that you know the answers and all you need to do is find the way to get to them. In this case, their goal was not the much needed twenty year review of the DSM-IV they were being asked to do. Instead, they wanted to move psychiatry to a Neuroscience Valhalla using the DSM-5 as a vehicle for change as Dr. Spitzer had done 30 years before.

We all know that pursuing neuroscience is the right thing for researchers to do, but we don’t know what might be discovered in that future, and we’re in no position to base our diagnostic evaluation of patients now on what might be known later or what we wish we already knew. It’s an arrogant agenda to be sure, but more importantly, it’s a diversion from the assigned task and the harbinger of a DSM-5 that would turn out to be more a victim of neglect than an improved tool.

So, at the 11th hour, they were forced to admit what they should have known back in 2002 when they’d hatched this grandiose plan – they’d built their house on sand, and perhaps done the cause of neuroscience more harm than good. We’d be much happier cheering for solid baby steps than being recurrently disappointed by failed giant leaps…
Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5
by David J. Kupfer, M.D. and Darrel A. Regier, M.D., M.P.H.
American Journal of Psychiatry 168:672-674, 2011.
[full text available on-line]

In the initial stages of development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, we expected that some of the limitations of the current psychiatric diagnostic criteria and taxonomy would be mitigated by the integration of validators derived from scientific advances in the last few decades. Throughout the last 25 years of psychiatric research, findings from genetics, neuroimaging, cognitive science, and pathophysiology have yielded important insights into diagnosis and treatment approaches for some debilitating mental disorders, including depression, schizophrenia, and bipolar disorder. In A Research Agenda for DSM-V, we anticipated that these emerging diagnostic and treatment advances would impact the diagnosis and classification of mental disorders faster than what has actually occurred…

I take the following quote from their report on their failed Field Trials as the closing parenthesis to the DSM-5 enterprise:

DSM-5 Field Trials in the United States and Canada, Part II: Test-Retest Reliability of Selected Categorical Diagnoses and Analytic Approaches
by Darrel A. Regier, William E. Narrow, Diana E. Clarke, Helena C. Kraemer, S. Janet Kuramoto, Emily A. Kuhl, and David J. Kupfer
American Journal of Psychiatry. 2012 October 30, AJP in Advance

"However, maximizing the reliability of our current categorical diagnostic conventions is not the only or ultimate goal. As with all of medicine, the goal is to move beyond reliability to a better assessment of the validity of disorders identified by our diagnostic criteria. The DSM-5 proposal to obtain “cross-cutting” measures of 13 psychological symptom domains, described by Narrow et al., is intended to provide a more dimensional description of patient presentations than can be captured by existing DSM-IV diagnostic criteria and boundaries. This approach is also consistent with the NIMH Research Domain Criteria [RDoC] project, which is attempting to identify both biological and symptomatic dimensional measures of psychopathology that correlate with genetic, neuroimaging, and neuropsychological factors irrespective of current diagnostic boundaries."
I think what I [maybe we] had missed all along the road is that the leaders of the DSM-5 project didn’t believe in the DSM system of Dr. Spitzer and later Dr. Frances any more. They were impatient to move from the atheoretical frame to something objective – from reliability to validity. Their wish to correlate the newer tools of neuroscience with clinical diagnosis had failed, and they almost seem to be blaming the diagnoses themselves – hoping to find some other diagnostic framework or, in the case of the RDoC, building diagnoses based on the results of the technologies:
"Emil Kraepelin, who pioneered the separation of schizophrenic and affective psychoses into separate diagnostic groups in 1898, noted later in a 1920 publication— prescient in its anticipation of a current polygenetic environmental interaction model of mental disorders—that the strict separation of these categorical diagnoses was not supported. We are now coming to the end of the neo-Kraepelinian era initiated in the U.S. by Robins and Guze with a renewed appreciation of both the benefits and limitations of a strict categorical approach to mental disorder diagnosis."
They evoke the ghost of Emil Kraepelin as someone who would agree with them in assuming that the "current polygenetic environmental interaction model of mental disorders" is a given, and lament that the traditional psychiatric diagnostic schemes don’t yet support the model. As with the technologies of science [genetic, neuroimaging, and neuropsychological factors], since they couldn’t connect diagnosis to their "current polygenetic environmental interaction model," they no longer have faith in categorical clinical diagnosis or the neo-Kraepelinian manifesto and are in search of something to replace it. So they hope to move to whatever they mean by "dimensional" or "cross-cutting."
"The ultimate goal is to build on the progress achieved with categorical diagnoses by continuing with longitudinal follow-up of patients with these diagnoses, incorporating cross-cutting dimensional measures judiciously into the diagnoses where they prove useful, and in some cases recommending simple external tests [such as a cognitive test for mild neurocognitive disorder] that might improve the reliability and move toward a more mature scientific understanding of mental disorders. A noted philosopher of science, Carl Hempel, observed that “although most sciences start with a categorical classification of their subject matter, they often replace this with dimensions as more accurate measurements become possible”. Clinicians think dimensionally and adjust treatments to target different symptom expressions in patients who may have the same categorical diagnosis. The intent of DSM-5 is to provide a diagnostic structure that will more fully support such dimensional assessments with diagnostic criteria revisions, specifiers, and cross-cutting symptom domain assessments. The goal is to support better measurement-based care and treatment outcome assessment in an era when quality measurement and personalized medicine will require new diagnostic approaches."
Having failed to produce the neurobiological DSM they dreamed of, they see themselves as creating a DSM that will better support the more neurobiological findings surely just around the corner – the "measurement-based care and treatment outcome assessment in an era when quality measurement and personalized medicine" finally come around.

Notice that these paragraphs are filled with the technologies and hypotheses of the day – "current polygenetic environmental interaction model of mental disorders", "genetic, neuroimaging, and neuropsychological factors", "measurement-based care", "personalized medicine". This is the stuff of international symposia, of heated debates at neuroscience meetings, or brown bag chats among eager PhD candidates and NIMH fellows given to creative extrapolations. And these are also the thoughts of older neuroscientists nearing the ends of their careers hoping  to finally bring fruition to their long held dreams – beliefs about the trajectory of their science.

But the topic at hand is a usable, reliable diagnostic system for clinicians of all ilks – psychiatrists, social workers, psychologists, professional counselors, first responders, grief counselors – the people who live at the interface between mental health care and the patients seeking it. So while the framers were dreaming of a breakthrough in neuroscience research, the conflict-of-interest prone work-group members were obsessing about their idiosyncratic opinions and leading edge hypotheses like attenuated psychosis syndrome or the infamous somatic symptom disorder. But no-one was minding the shop. Best I can tell, they didn’t even believe in it enough to try. The category Major Depressive Disorder is ill-conceived, a source of endless misleading clinical trials, and fails to discriminate between depressions likely to actually have a biological/genetic substrate and those rooted in the personal experience and narrative. Their approach to the problem of the "Bipolar Child" was to rename the syndrome, not to delve into the diagnostic dilemma at hand. The category Generalized Anxiety Disorder is as over-inclusive as MDD, but wasn’t touched. By any measure, psychiatrists and primary care physicians are globally overmedicating patients – barely mentioned. Withdrawal states from psychoactive medications and other side effects are being either ignored or interpreted as mental illness – an unaddressed problem. And when the Field Trials showed their DSM-5 to be faulty in the only objective criteria we have, reliability, they blamed the system itself.

There’s nothing wrong with their hypotheses and dreams – it’s what scientists do. But the revision of a code book is no place for that kind of dreaming. It’s supposed to be about right now, what we know right now. Dr. Spitzer got away with a radical change in psychiatry using the code book because he found a rational practical key to make it acceptable – reliability. His DSM had holes, loopholes, unintended consequences, down-right mistakes. Subsequent revisions remedied some, but created others. The job of the DSM-5 Task Force was to do something about those problems – not dream of a hypothetical future. Psychiatry is badly off-track. If they wanted to do something big, they could’ve brought us back towards center rather than spin us further into the ether…

    Bernard Carroll
    December 29, 2012 | 11:31 AM

    From the Research Agenda: “In the ongoing quest to improve our psychiatric diagnostic system, we are now searching for new approaches to understanding the etiological and pathophysiological mechanisms that can improve the validity of our diagnoses and the consequent power of our preventive and treatment interventions venturing beyond the current DSM paradigm and DSM-IV framework.” For turgid prose this is hard to beat. It is so bad that it approaches poverty of content. Why would we trust people who cannot write simple declarative sentences to revise an entire diagnostic manual? There is a saying that people who cannot write clearly cannot think clearly.

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