DSM-5 retrospective II… »
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DSM-5 retrospective I…

Posted on Friday 3 January 2014

Something very unusual happened in the process of the revision of the psychiatric diagnostic manual – the DSM-5 revision published last May. The leaders of the previous revisions, Robert Spitzer [DSM-III, DSM-IIIR] and Allen Frances [DSM-IV], both became outspoken critics of the enterprise and went public with their dissatisfaction. Dr. Spitzer was refused access the the minutes of the DSM-V meetings, and then found out that all the members of the Task Force had signed confidentiality agreements. In a series of articles in the Psychiatric News in 2008 and early 2009, he repeatedly pointed out that secrecy was unprecedented and incompatible with the charge of the Task Force. Dr. Allen Frances declined to join Dr. Spitzer’s campaign until May when he learned about some of the things the DSM-5 Task Force were contemplating, and he went public with his concerns with what became the very public campaign that continues to the present [see dangerous men…]. The response from the APA was silence, defensiveness, or attacks – but never engagement.

As this increasingly loud controversy filled our airways, I went back and read the book that had introduced the whole DSM-5 process in 2002, A Research Agenda for the DSM-V [available as a pdf]. I’ve mentioned this book repeatedly but have never gotten much of a response. I think it’s a book of dirty tricks that contains the roots of what came later. From the Introduction [page 18 of the PDF]:
Need to Explore the Possibility of Fundamental Changes in the Neo-Kraepelinian Diagnostic Paradigm

… Disorders in DSM-III were identified in terms of syndromes, symptoms that are observed in clinical populations to covary together in individuals. It was presumed that, as in general medicine, the phenomenon of symptom covariation could be explained by a common underlying etiology. As described by Robins and Guze [1970], the validity of these identified syndromes could be incrementally improved through increasingly precise clinical description, laboratory studies, delimitation of disorders, follow-up studies of outcome, and family studies. Once fully validated, these syndromes would form the basis for the identification of standard, etiologically homogeneous groups that would respond to specific treatments uniformly.

In the more than 30 years since the introduction of the Feighner criteria by Robins and Guze, which eventually led to DSM-III, the goal of validating these syndromes and discovering common etiologies has remained elusive. Despite many proposed candidates, not one laboratory marker has been found to be specific in identifying any of the DSM-defined syndromes. Epidemiologic and clinical studies have shown extremely high rates of comorbidities among the disorders, undermining the hypothesis that the syndromes represent distinct etiologies. Furthermore, epidemiologic studies have shown a high degree of short-term diagnostic instability for many disorders. With regard to treatment, lack of treatment specificity is the rule rather than the exception.

The efficacy of many psychotropic medications cuts across the DSM-defined categories. For example, the selective serotonin reuptake inhibitors [SSRIs] have been demonstrated to be efficacious in a wide variety of disorders, described in many different sections of DSM, including major depressive disorder, panic disorder, obsessive-compulsive disorder, dysthymic disorder, bulimia nervosa, social anxiety disorder, posttraumatic stress disorder, generalized anxiety disorder, hypochondriasis, body dysmorphic disorder, and borderline personality disorder. Results of twin studies have also contradicted the DSM assumption that separate syndromes have a different underlying genetic basis. For example, twin studies have shown that generalized anxiety disorder and major depressive disorder may share genetic risk factors [Kendler 1996]…
I would never be a person accused of defending the DSM-III or the Feighner Criteria, but my reading of Kupfer et al is that they’re making a Straw Man Argument here – presenting things in a certain way so as to be able to shoot them down. And they don’t mention what Dr. Spitzer said in the Introduction to his DSM-III:
For most of the DSM-III disorders, however, the etiology is unknown. A variety of theories have been advanced, buttressed  by evidence – not always convincing – to explain how these disorders came about. The approach taken in DSM-III is atheoretical with regard to etiology or pathophysiological process except for those disorders for which this is well established and therefore included in the definition of the disorder. Undoubtedly, with time, some of the disorders of unknown etiology will be found to have specific biological etiologies, others to have specific psychological causes, and still others to result mainly from a particular interplay of psychological, social, and biological factors. The major justification for the generally atheoretical approach taken in DSM-III with regard to etiology is that the inclusion of etiological theories would be an obstacle to use of the manual by clinicians of varying theoretical orientations, since it would not be possible to present all reasonable etiologic theories for each disorder.
Robert Spitzer, in the DSM-III, p 6.
There are plenty of other more likely explanations for the disappointments they mention with the previous DSMs. There’s a major flaw in the DSM system that would explain much of what they complain about. The creation of the omnibus unitary Major Depressive Disorder [MDD] destroyed the most likely candidate for biomarkers, Endogenous Depression or Melancholia, a category Dr. Kupfer himself had studied productively in the past [REM latency: a psychobiologic marker for primary depressive disease]. Who ever said that the conditions listed in the DSM were biological or genetic in origin? We hypothesis that some are, pending confirmation. I agree with some of those hypotheses. But what is it about the medications that suggests disease specificity? More likely, they are symptomatic medications, unrelated to underlying etiology. And the more basic concern that the biologic measures don’t map onto DSM categories as Drs. Robins and Guze predicted may well have the same significance – the biological hypotheses are simply incorrect.

It’s an odd book in that it looks at thirty years of evidence of a failed set of hypotheses and concludes that the hypothesis is right but we’re just not collecting the right evidence – the truth was in the hypothesis, not in the test results. Ergo, the diagnostic system based on the predictions was wrong, because it didn’t produce the expected results themselves. I’m of course making something of a Straw Man Argument myself here. I support the research into the biological basis of conditions that warrant that exploration. I’m arguing against the global point they’re making, not all the specifics. The rest of this book lays out a plan to explore other ways to classify mental illness, chasing the biology and the responses to biological treatment.  They say very little about revising the DSM. Their focus was on changing it. And that continued in a series of expensive and extensive symposia over the next several years:
I’m covering monotonous ground here for a reason. Doctor Spitzer knew something was wrong. He focused on the secrecy. Why be secret? Dr. Frances knew something was wrong too. He focused on the implications of some of the changes the Task Force were considering, and on what they weren’t doing [which I would paraphrase as their assigned task, revise the DSM]. I propose that both of them were reacting something more fundamental. The DSM-5 Task Force leaders didn’t like the DSM-IV. They didn’t want to revise it. They wanted to change it into the biologically based manual they wanted it to be, that Robins and Guze had dreamed of it being, and that the pharmaceutical industry had been pushing towards for decades. Classify and treat mental illness by symptoms, not disorders. They wanted to move the system to meet the neuroscience and the psychopharmacology rather that fit those things to our patients. And the reason I’m reiterating this history is that I think we’ve recently been given a window into the DSM-5 Task Force that supports this view. But before I close this piece, let me mention that they admitted that was their goal late in the game:
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 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 the 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…
Psychiatric Diagnosis in the Lab: How Far Off Are We?
Medscape News
by Jeffrey A. Lieberman, MD
09/28/2011

…we anticipated that this iteration of the DSM would incorporate biological markers and laboratory-based test results to augment the historical and phenomenologic criteria that traditionally are used to establish psychiatric diagnoses. Sadly, this has proved to be beyond the reach of the current level of evidence…
So mine is a conspiracy theory. The leaders of the DSM-5 Task Force and their colleagues wanted to change the DSM-5 into a system that mirrored their own view of psychiatry and mental illness. It was the view Dr. Insel came to call Clinical Neuroscience. And they wanted to orient the diagnostic system accordingly, to fit the findings of neuroscience and to fit the psychopharmacology of the day. Their goal was to highjack the revision of the manual to make a rather dramatic paradigm shift. Thus all of the secrecy. Thus the oddball revisions they did come up with. Thus their complete failure to address their assigned task – revising the system we had. Dimensional diagnosis was a major part of that plan – fit the diagnosis and treatment of mental illness to what the drugs did and neuroscience findings showed. And I would accuse them of being heavily motivated by their own connections with industry and commercial interests. I think Dr. Frances and I might disagree on that last part, but I’m unswerving, particularly in light of the recent revelations about some of the unacknowledged activities of the DSM-5 leader – Dr. David Kupfer…
  1.  
    Joel Hassman, MD
    January 3, 2014 | 10:56 AM
     

    I just don’t get the problem here with the DSM5? If it is inherently corrupt and self serving for a few psychiatrists at the end of the day, and if it takes the profession as a whole and the rest of medicine to decide to accept or reject the premise of this new manual, then, why can’t the majority of physicians and other mental health professionals just reject it, by not buying it nor refusing to use any new codes in it? After all, aren’t we bound by ICD codes at the end of the day anyway?

    Ever watch the movie “12 Angry Men” with Henry Fonda, about the jury deciding the fate of a man accused of killing his father? Towards the last 1/3 of the movie, when the bigot goes into his tirade about how he knew the man was guilty simple because the defendant was black, isn’t it powerful how the rest of the men in the room silenced him simple by shunning him, turning their backs and making no eye contact, no hint of validation to the bigot’s commentary?

    I think this kind of behavior still has power. But, it requires energy and thought, effort and coordination between people. I think it is beyond time to not only shun the APA and their corrupt leadership, but, when it is obvious the APA risks being made irrelevant, then they should be shamed and humiliated by strong words.

    Tyranny succeeds primarily by forcing people to be silent and complicit. Is that what you are about, colleagues out there? Just made to shut up and be coerced to cooperate?

    The APA is not an organization of leaders, but, tyrants and criminals. And if you as a provider don’t want to take a stand and do what is right, then just keep sitting there and be silent. Eventually, you will be irrelevant too, but will have more to lose than those charlatans who have filled their treasure chests, just ignoring all the blood covering those coins.

    It is just incredible to watch the antisocial element pervade society of late. Like Senator Padme says at the end of “Revenge of the Sith”, as the Emperor takes control of the system, “so this is how democracy dies, to the sound of thunderous applause!”

    Indeed!

  2.  
    Suzy Chapman
    January 3, 2014 | 11:42 AM
     

    The ICD-9-CM and ICD-10-CM coding systems are subject to annual revisions by NCHS/CMS via public review meetings held twice a year (in March and September), followed by public comment periods.

    At the September 2013 ICD-9-CM Coordination and Maintenance Committee meeting, APA presented proposals for new codes for addition to the ICD-10-CM. APA states that the new codes, if approved [by NCHS/CMS], would probably not be added to ICD-10-CM until 2015.

    http://www.cdc.gov/nchs/data/icd/icd_topic_packet_sept_181913.pdf

    From Page 32 of the meeting Diagnosis Agenda onwards:

    Binge eating disorder (BED);
    Disruptive mood dysregulation disorder (DMDD);
    Social (pragmatic) communication disorder;
    Hoarding disorder;
    Excoriation (skin picking) disorder;
    Premenstrual dysphoric disorder (PMDD)

    On Page 45 and 46 of the meeting Diagnosis Agenda, under Additional Tabular List Inclusion Terms for ICD-10-CM, a number of other changes to specific ICD-10-CM Chapter 5 F codes were proposed, including the following additions to the ICD-10-CM:

    Somatic symptom disorder (proposed as Inclusion term to ICD-10-CM F45.1 Undifferentiated somatoform disorder)

    Illness anxiety disorder (proposed as Inclusion term to ICD-10-CM F45.21 Hypochondriasis).

    If NCHS rubber stamps the addition of Somatic Symptom Disorder as an official codeable diagnostic term within ICD-10-CM, it could leverage the future replacement of several existing ICD-10-CM Somatoform disorders categories with this new, poorly validated, single diagnostic construct, bringing ICD-10-CM in line with DSM-5.

    There are implications for ICD-11, too. Once SSD is inserted into ICD-10-CM, the presence of this term within the U.S. adaptation of ICD-10 may make it easier for ICD-11 Revision Steering Group to justify the replacement of several existing ICD-10 Somatoform disorders categories with a single, new ICD construct contrived to incorporate SSD-like characteristics and facilitate harmonization between ICD-11 and DSM-5 disorder terms and diagnostic criteria.

  3.  
    Suzy Chapman
    January 3, 2014 | 12:31 PM
     

    The following new DSM-5 disorders are already proposed for addition to ICD-11 and have been displaying for some time in the public version of the ICD-11 Beta draft:

    Binge eating disorder: currently proposed to be coded under Feeding and eating disorders;

    Hoarding disorder: currently proposed to be coded under Obsessive-compulsive and related disorders;

    Excoriation disorder (skin-picking disorder): currently proposed to be coded under Obsessive-compulsive and related disorders, under parent Body-focused repetitive behaviour disorders;

    Premenstrual dysphoric disorder (PMDD): currently proposed to coded under dual parents, under Chapter 15 Diseases of the genitourinary system > Premenstrual tension syndrome, and also under Chapter 5 Depressive disorders. A draft ICD-11 Definition has been populated for PMDD.

  4.  
    Hannah S. Decker
    January 3, 2014 | 6:06 PM
     

    Hi Mickey: This is not for posting on line, but I don’t know how else to get in touch with you.
    A while back you quoted something I had written for Psychiatric Times about the DSM-5 process. We then had a correspondence and you told me about your background.
    I am writing now to tell you that I published last April (Oxford) my book on DSM-III. It’s called The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry.” While some of it provides background and is historical, the bulk is based on APA Archives never before used. I think you would find it useful to your concerns.
    To remind you, I am a cultural historian of psychiatry and a history professor at the University of Houston. I am also an Adjunct Professor of Medical History at the Menninger Dept. of Psychiatry at the Baylor College of Medicine and on the Adjunct Faculty of the Center for Psychoanalytic Studies here in Houston.
    Here’s a link to the Oxford website about my book. It’s the original; let me know if I have to get you a newer one.
    http://global.oup.com/academic/product/the-making-of-dsm-iii-9780195382235?cc=us&lang=en&
    Best wishes for the New Year.
    Hannah Decker

  5.  
    snoring
    January 4, 2014 | 1:42 AM
     

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