{"id":25561,"date":"2012-08-05T07:30:09","date_gmt":"2012-08-05T11:30:09","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=25561"},"modified":"2012-08-05T06:01:57","modified_gmt":"2012-08-05T10:01:57","slug":"ditto","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2012\/08\/05\/ditto\/","title":{"rendered":"ditto&#8230;"},"content":{"rendered":"<br \/>\n<table width=\"250\" cellspacing=\"0\" cellpadding=\"2\" border=\"0\" align=\"center\">\n<tr>\n<td align=\"left\">This is the way the world ends<br \/>  This is the way the world ends<br \/>  This is the way the world ends<br \/>  Not with a bang but a whimper.<\/td>\n<\/tr>\n<tr>\n<td align=\"right\"><em>The Hollow Men<\/em> | T.S.Eliot | 1925<!--\/td--><\/td>\n<\/tr>\n<\/table>\n<blockquote>\n<div align=\"center\"><a href=\"http:\/\/neuroskeptic.blogspot.com\/2012\/08\/dsm-5-rip.html\" target=\"_blank\"><u><strong><font color=\"#200020\">DSM-5 R.I.P?<\/font><\/strong><\/u><\/a><br \/>    <strong><font color=\"#200020\">Neuroskeptic<\/font><\/strong><br \/>    August 3, 2012<\/div>\n<p>    <\/p>\n<div align=\"justify\"><sup>Yesterday, the proposed new DSM-5 revision of the American Psychiatric Associations &quot;Bible of Psychiatry&quot; came under yet more <a href=\"http:\/\/dxrevisionwatch.wordpress.com\/\" target=\"_blank\">criticism<\/a>. Aaron T. Beck, the father of currently-mega-popular cognitive behavioural therapy, <u><strong><a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed?term=22850300\" target=\"_blank\">started it off with an attack<\/a><\/strong><\/u>  on the upcoming changes to one diagnosis, Generalized Anxiety Disorder;  but many of the points also apply to the other DSM-5 proposals:<\/sup><\/div>\n<div align=\"justify\">\n<ul>\n<div><sup>The lack of specific features, which is  the primary issue for GAD, will not be addressed in DSM-5. The hallmark  of the condition will remain pathological worry, although it also  characterizes other disorders. Likewise, the proposed behavioral  diagnostic criteria lack specificity for GAD, and it is not clear how  these will be assessed. The proposed changes will lower the diagnostic  threshold for GAD in DSM-5&#8230; many currently subthreshold cases will  qualify for this diagnosis. The likely inclusion of many such  &quot;false-positives&quot; will result in an artificial increase in the  prevalence of GAD and will have further negative consequences.<\/sup><\/div>\n<\/ul><\/div>\n<div align=\"justify\"><sup>Then from across the Atlantic, and also across the psychotherapy-vs-medication divide, came <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed?term=22850770\" target=\"_blank\"><u><strong>another piece of criticism<\/strong><\/u><\/a>. The authors are all associated with the European Medicines Agency [EMA, Europe&#8217;s equivalent of the FDA], or with national drug regulators. Although they&#8217;re writing in a personal capacity, this is still big news if you ask me. These authors start out by saying that the EMA is broadly in favour of  DSM reform, but they then attack one of the key DSM-5 innovations &#8211; the  move towards &#8216;<u><strong><a href=\"http:\/\/www.dsm5.org\/ProposedRevisions\/Pages\/Cross-CuttingDimensionalAssessmentinDSM-5.aspx\" target=\"_blank\">dimensional measures<\/a><\/strong><\/u>&#8216; of symptoms in addition to diagnoses:<\/sup><\/div>\n<div align=\"justify\">\n<ul>\n<div><sup>One of our main concerns is related to potential future [drug]  indications based on an effect on a dimension that is independent of  diagnostic categories [although we acknowledge that non-specific claims  are common in other areas, such as analgesics for pain]. As an example,  cognitive impairments are common in psychiatric disorders, but they do  not have a unique clinical pattern or a unitary cause. We therefore believe that, at present,  such a cross-cutting approach may increase heterogeneity in patient  populations and make the assessment of the benefit&ndash;risk balance more  difficult. Similarly, the use of dimensions as key secondary end points  in many different diagnostic categories may lead to pseudospecific  indications and polypharmacy. As a general rule, a therapeutic  indication should be a well-recognized clinical entity that is clearly  distinguishable from other conditions&#8230;<\/sup><\/div>\n<\/ul><\/div>\n<div align=\"justify\"><sup>They also echo Beck in warning of over-diagnosis and over-medicalization:<\/sup><\/div>\n<div align=\"justify\">\n<ul>\n<div><sup>Current proposals to reclassify some conditions that were subthreshold  or prodromal as distinct syndromes or disorders could have implications  for clinical trials. The inclusion of milder or very early cases of  psychiatric disorders may lead to an increase in the number of  non-disordered [false-positive] patients in clinical trials, and to an  increase in the placebo effect, as less severe cases are more likely to  respond to placebo. It may therefore be difficult to show a  statistically significant difference [of drug over placebo]&#8230; This raises another highly controversial  issue: the risk of medicalization of the normal population. In this  respect, a strong concern comes from the proposal to remove bereavement  exclusion from the criteria for major depressive disorder, implying that  all individuals with &lsquo;normal grief&rsquo; might be considered as patients in  the future.<\/sup><\/div>\n<\/ul><\/div>\n<div align=\"justify\"><sup>Regular readers will remember that I&#8217;ve covered both overdiagnosis screwing up clinical trials, and the bereavement debate. Two and a half years ago, shortly after the first draft of the DSM-5 was made public, I predicted that the eventual release of DSM-5 would be a non-event because,  by then, it would have been widely debated and criticized, destroying  the illusion of expert consensus that any such document must have in  order to succeed. I think events have borne this out. An awful lot of professionals, patients, and their relatives, will  reject the changes in favour of sticking with the DSM-IV or other  criteria. Without swift and general acceptance, a document like the DSM  is just paper. It seems increasingly likely that the DSM-5 is going to be dead on arrival.<\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\"><em>ditto<\/em>&#8230;<\/div>\n<div align=\"justify\">&nbsp;<\/div>\n<div align=\"justify\">Coming soon to a blog near you, <strong><font color=\"#200020\">How to use the ICD in Clinical Practice<\/font><\/strong> [in the US]&#8230; <\/div>\n","protected":false},"excerpt":{"rendered":"<p>This is the way the world ends This is the way the world ends This is the way the world ends Not with a bang but a whimper. The Hollow Men | T.S.Eliot | 1925 DSM-5 R.I.P? Neuroskeptic August 3, 2012 Yesterday, the proposed new DSM-5 revision of the American Psychiatric Associations &quot;Bible of Psychiatry&quot; [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-25561","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/25561","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=25561"}],"version-history":[{"count":8,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/25561\/revisions"}],"predecessor-version":[{"id":25568,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/25561\/revisions\/25568"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=25561"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=25561"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=25561"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}