Hearing those sounds of silence coming from the DSM-5 Task Force? No further comment on or results from the Field Trials. No commentary from the principals. If you don’t follow Suzy Chapman’s blog [Dx Revision Watch], you might even forget that there’s a revision coming out in less than a year. And most of the recent information there is about the ICD rather than the DSM-5. This once fertile area for daily dialog has suddenly gone flat as a pancake – off the radar. Their silence isn’t that hard to understand. It’s been kind of a rough year for the Task Force. This time last year, they were forced to admit that their grand plans for an evidence-based, sure-enough bio-medical classification hadn’t worked out as well as they’d hoped [actually hadn’t worked out at all]: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.
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…
Then this January, they had to let us know that there wasn’t going to be a very exciting set of results from the long awaited Field Trials:
DSM-5: How Reliable Is Reliable Enough?
by Helena Chmura Kraemer, David J. Kupfer, Diana E. Clarke, William E. Narrow, and Darrel A. Regier
American Journal of Psychiatry 2012 169:13-15.
… We previously commented in these pages on the need for field trials. Our purpose here is to set out realistic expectations concerning that assessment. In setting those expectations, one contentious issue is whether it is important that the prevalence for diagnoses based on proposed criteria for DSM-5 match the prevalence for the corresponding DSM-IV diagnoses. However, to require that the prevalence remain unchanged is to require that any existing difference between true and DSM-IV prevalence be reproduced in DSM-5. Any effort to improve the sensitivity of DSM-IV criteria will result in higher prevalence rates, and any effort to improve the specificity of DSM-IV criteria will result in lower prevalence rates. Thus, there are no specific expectations about the prevalence of disorders in DSM-5. The evaluations primarily address reliability…
Their presentation of the Field Trial results at the APA in May was indeed disappointing [see updated table…]:
Preliminary results are mixed for the recently completed field trials for the upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), according to the first public presentation of the findings here at the American Psychiatric Association’s (APA’s) 2012 Annual Meeting. Diagnostic criteria for autism spectrum disorder, posttraumatic stress disorder (PTSD), and attention-deficit/hyperactivity disorder (ADHD) in children were found to be very reliable. Conditions that did not do well included major depressive disorder (MDD), in adults and in children, and general anxiety disorder (GAD). According to Darrel Regier, MD, vice-chair of the DSM-5 task force, the poor scores for MDD may be attributable to "co-travelers," such as PTSD, major cognitive disorder, or even a substance use disorder, which often occur concurrently with depression. "Patients often don’t come in a single, simple diagnosis in clinical practice," Dr. Regier told Medscape Medical News. "If you have a patient with PTSD and major depression, the one that will probably get the most attention is PTSD. And that’s what we found in our study." He added that analysis of the field trials is ongoing and that the results presented at the meeting are preliminary. Members of the task force said they hope to publish the full results "within a month"…
The "Members of the task force said they hope to publish the full results ‘within a month’" part never materialized. It still hasn’t. With this run of recurrent bad news and the resultant waves of criticism, they just went silent. There’s another possible outside reason for their silence discussed in detail on Dx Revision Watch – a problem of timelines involving the ICD Committees, HHS, and the APA. It’s complicated and I’ll leave it to Suzy to explain it:
I picked my title for this post unconsciously, but its origin isn’t that hard to figure out. It’s from the 1929 novel by Erich Maria Remarque taken from his experiences as a German soldier in World War I. The title is from an official communique and is intended to be ironic in that the novel’s protagonist, Paul, has just been killed. It’s a symbol of the tragic disconnect between the high command and the actual soldiers fighting the war. A clinical diagnosis is something doctors do for patients, a gift even if it’s bad news. It ends a period of uncertainty and helps the patient move on to the next step – whether by offering a cure, or a treatment, or relief from worry, or at least knowledge about prognosis. In the part of my mind that matters, I obviously think that the DSM-5 is an official communique that’s way off that mark…
It’s gotten easier to spot the goal of the DSM— it i an administrative tool, used to justify cost of services. Common sense dictates this tool has no value in clinical practice, and no need for patient input.
The REAL disconnect I see, that is very baffling, almost painfully so, is how the authors of the DSM and the authors all administrative tools used to justify cost of services, have failed to notice that their *error* is blatantly obvious—- even to the layperson, and especially patients. In the absence of patient input, or even solid information for evaluating patient complaints, symptoms, etc. , Psychiatry looks more and more like the monster it has been called for over a century. It, psychiatry, that is; bears no resemblance to a medical speciality and likewise has no evidence of efficacy— in anything but securing third party payments and securing funding from NIMH for fly by night research.
You know that queasy feeing you get when someone is embarrassing themselves–badly— and can’t see IT— so reflects on how or why iIT’S happening?? I have this feeling most everyday reading this and madinamerica— need to take a break as loss of appetite can be a serious effect from this feeling…. or indicative of a budding eating disorder via the DSM…
Oops! meant to write “so, CANNOT reflect on how or why… ”
THEY don’t get that we already know the focus is not patient care, treatment… PATIENT… anything!
The more they present their reasoning, the more obvious their *disconnect* becomes…
The patent response for defending the DSM is evidence of a deaf ear to complaints and outrage from colleagues to, public ,to patients. I think the underlying message is: “YOUR feedback was not solicited” .