Why DSM-V Doesn't Worry Me

A friend sent me a link to an article about the upcoming fifth edition
of the American Psychiatric Association's Diagnostic and Statistical
Manual.  The article speaks of flaws in the process, and warning
of dire "unintended consequences." href="http://www.psychiatrictimes.com/print/article/10168/1425378?printable=true">

href="http://www.psychiatrictimes.com/print/article/10168/1425378?printable=true">A
Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences

Allen Frances, MD

June 26, 2009

Psychiatric Times

...I believe that the work on DSM-V has displayed the most
unhappy combination of soaring ambition and weak methodology. First we
will explore the excessive ambition, because it has encouraged an
excessive tolerance for risk taking.



The DSM-V goal to effect a "paradigm shift" in psychiatric diagnosis is
absurdly premature. Simply stated, descriptive psychiatric diagnosis
does not now need and cannot support a paradigm shift...



...If the potential gains of DSM-V are extremely modest, the potential
risks are great and largely unrecognized. Making changes in the
diagnostic system is never cheap. Just as with an individual patient,
the first consideration in revising the diagnostic classification must
always be to "do no harm"--and the harm inflicted by changes in the DSM
diagnostic system can come in many, and usually unexpected, forms...



The most obvious cost is the significant burden to the field of having
to learn and adapt to any changes included in DSM-V...



...For instance, a seemingly small change can sometimes result in a
different definition of caseness that may have a dramatic and totally
unexpected impact on the reported rates of a disorder. Thus are false
"epidemics" created. For example, although many other factors were
certainly involved, the sudden increase in the diagnosis of autistic,
attention-deficit/hyperactivity, and bipolar disorders may in part
reflect changes made in the DSM-IV definitions...



...This issue becomes particularly relevant when one considers the
skillful pressure likely to be applied by the pharmaceutical industry
after the publication of DSM-V. It has to be assumed that they will
attempt to identify every change that could conceivably lead to a
marketing advantage--often in ways that will not have occurred to the
DSM-V Task Force. To promote sales, the companies may sponsor
"education" campaigns focusing on the diagnostic changes that most
enhance the rate of diagnosis for those disorders that will lead to the
increased writing of prescriptions. As I will discuss, there is a great
risk of many new "epidemics" based on changes suggested for DSM-V...



..Undoubtedly, the most reckless suggestion for DSM-V is that it
include many new categories to capture the subthreshhold (eg, minor
depression, mild cognitive disorder) or premorbid (eg, prepsychotic)
versions of the existing official disorders...



...Another DSM-V innovation would create a whole new series of
so-called behavioral addictions to shopping, sex, food, videogames, the
Internet, and so on. Each of these proposals has the potential for
dangerous unintended consequences by inappropriately medicalizing
behavioral problems; reducing individual responsibility; and
complicating disability, insurance, and forensic evaluations. None of
these suggestions is remotely ready for prime time as an officially
recognized mental disorder...

Dr. Frances made a few other points that I didn't include in the
excerpt.  One is the allegation that the process for developing
DSM-V has been "inexplicably closed and secretive."  Another is
that the persons developing the Manual are not given sufficient a
priori instruction and guidelines.  The third is that the
field trials may not be sufficiently rigorous.



It is not a simple task to address each of these issues.  This is
because the article is neither all bad, nor all good.  It is
necessary to examine each point on its merits or lack thereof.



His concern about a paradigm shift stems from the proposed introduction
of dimensional ratings to the diagnostic system.  He states that
there are two problems with this: it would be too complicated to use in
daily practice, and the science to support it is not well
developed ("absurdly premature"). 



He's probably correct about the first point.  As much as I hate to
say it, many of my colleagues probably won't take the time or effort to
use a more complicated system properly.  Cripes, they often don't
take the time and effort to use the current system properly. 
Would a system that is even more nuanced and complex make things any
worse?  Hard to say, but it is not obvious that it would make
things worse.  It has the potential to make things better. 
Plus, if the new system turned out to be useful, perhaps people would
learn to use it properly.



As for the second point, that the science is not yet well developed:
that also is true, but for a different reason.  He is correct that
the science does not yet support a paradigm shift.  But how are we
to develop the science, without some initial attempt at a more nuanced
method of characterizing what we see?  True, we could go back to
the situation that existed in the DSM-II days.  Back then, there
was DSM-II, and a parallel diagnostic scheme, the  Research
Diagnostic Criteria, or RDC.  It was awkward to
have two systems, but it did work.  The RDC had a big influence on
the development of DSM-III.  In fact, href="http://www.garfield.library.upenn.edu/classics1989/A1989U309700001.pdf">it
led to a paradigm shift (PDF link). 



The problem with going back to having two systems, is that the DSM is
much more important now than
it was in the 70s.  Most published research now uses DSM, not
RDC.  So if we went back to a system that uses two manuals, then
some research would be based upon one system, while the
rest would use the other system.  It is bad enough that older
research is based upon DSM-III diagnoses, while more recent research
uses DSM-IV criteria.  But I have to think that it would be much
more difficult to make use of the research if two entirely separate
systems were in use simultaneously.  There would be all kinds of
chaos if that were the case.  Imagine trying to do a meta-analysis
in that situation!



His next objection relates to the possibility of expanding the number
of persons who would receive a formal diagnosis.  He envisions two
ways that this could happen.  One is that changes in wording could
expand the number of persons who qualify for a particular diagnosis
(possibly influenced by pharmaceutical interests).  The other is
by including subsyndromal conditions:

Undoubtedly, the most reckless suggestion for DSM-V is that
it include many new categories to capture the subthreshhold (eg, minor
depression, mild cognitive disorder) or premorbid (eg, prepsychotic)
versions of the existing official disorders.  The beneficial
intended purpose is to improve early case finding and promote
preventive treatments. Unfortunately, however, the DSM-V Task Force has
failed to adequately consider the potentially disastrous unintended
consequence that DSM-V may flood the world with tens of millions of
newly labeled false-positive "patients."

OK.  Here, I don't agree with either side.  Creating a
formalized method of labeling persons with subthreshold conditions will
not flood the world with tens of millions false-positive
patients.  It also will not result in any meaningful advance in
the practice of medicine.  The fact is, we already have a
way of labeling such persons.  If some persons have some, but not
all, of the features of, say, obsessive-compulsive disorder, we say
they are persons who have some, but not all of the features of
obsessive-compulsive disorder.  Or we may say that they have
subsyndromal OCD.  Or some such verbiage.  We do not need a
new way to say that, because we already have a way to say it.  And
nothing will change if we come up with a different way to say
it.  



Furthermore -- and this is the more important point -- there is no
reason to assume that creating a new label will cause anything to
happen at all.  The way the system is supposed to work, is that
the designation of a diagnosis does not automatically cause anything to
happen.  The decision to initiate treatment is a private
transaction between the person providing the treatment, and the person
receiving the treatment. If the two of them decide that a certain
diagnosis ought to be treated, that it fine.  If they decide that
it should not be treated, that's fine too.  If one thinks that
treatment should be provided, but the other does not, then they talk
about it, work out their differences, or go their separate ways. 



Yeah, it is a bit naive of me to say that, because I know that there
are practitioners who don't adhere to that practice.  I also know
that it takes time and money to see doctors, and that some communities
don't have enough.  So a difference of opinion is not necessarily
benign.  But the point stands, that merely ascribing a diagnosis
does not automatically cause anything to happen.



Dr. Frances goes on to complain about the notion of creating labels for
persons with "so-called behavioral addictions to shopping, sex, food,
videogames, the
Internet, and so on."  I myself am not a fan of calling these
problems addictions, because that implies a correlation to
chemical addictions.  It is not clear to me that there is any
utility to that, and there is a risk of implying things that are not
really known.  If a person shops too much, just say they shop too
much.  Of say that they have impulse control disorder.  This
brings to mind those lists of
various phobias, with long Latin or pseudolatin names for things:
for example, the fear of the number thirteen ( face="new gothic nt">triskaidekaphobia), or of garlic
(alliumphobia).  Words like that are fun, but not very
useful. 




Another point: Dr. Frances complains that the persons developing DSM-V
have not received adequate guidance.  But this raises the
question: who is it that should be guiding them?  And who guides
the people who are guiding the people?  Presumably, the committees
are composed of qualified, senior physicians, who are capable of doing
a decent job.  Adding another layer of management is not going to
help.



This is not to say that there are no valid controversies about the
process of developing DSM-V.  There are.  Dr. Frances' point
about inadequate field trials is a good one.  After all, it is the
field trials that establish interrater reliability, which currently is
the best way to validated the diagnostic scheme.  There is not
excuse for short-circuiting that part of the process. 



There are other problems, too.  David Dobbs, one of the
professional science journalists at ScienceBlogs, href="http://scienceblogs.com/neuronculture/2009/07/dsm-v_psych_bus_hits_more_big.php">points
out one of them, in linking to Dr. Carlat's blog. 
Unfortunately, Dobbs makes a couple of errors (that are not central to
the problem he is pointing out):

The DSM isn't just a workbook; it's the theoretical
framework and the de-facto prescription guideline for American
psychiatry.

The DSM is not a theoretical framework.  In fact, it is written in
such a way as to be as atheoretical as possible.  Furthermore, it
is not a prescription guideline.  It is silent, or nearly so, on
the topic of prescribing medication.  It does have an important
role to play in decisions about prescribing, but it is not a
guideline.  These distinctions are aside from his point, which is
that DSM is a influential work. It influences the thoughts and the
actions of practitioners, patients, and various bystanders, such as
courts, insurance companies, and probably others.



Anyway, the post he links to, the one that mentions a valid problem, is
this one:

href="http://carlatpsychiatry.blogspot.com/2009/07/dsm-v-armageddon-part-2.html">The
DSM-V Armageddon, Part 2



Dr. Jane Costello has had enough of DSM-V, and has quit the prestigious
DSM-V Work Group on Disorders in Childhood and
Adolescence...Essentially, Dr. Costello resigned because she feels that
the DSM-V process is being rushed to completion without an adequate
scientific basis.

She's probably right.  They are working on an artificial
timetable.  Of course, there has to be some kind of timetable,
else the thing would never be completed.  We have to accept the
fact that the final product won't be perfect.  But there has to be
adequate time, for example, for proper field trials.  She also
complains (not included in excerpt) that one of the guiding principles
is not being followed.  The principle is that changes should not
be made without adequate empirical support.  There is room for
argument about what constitutes "adequate" support, but she seems to
feel that some decisions are being made with very little support. 
There is no sense to that.  We understand the the product will not
be perfect, but it does need to be better than what it replaces. 
Making changes that are based upon opinion is not likely to advance the
cause.  There is a place for opinion, but the DSM is not that
place.



Several pundits, including Dobbs and Carlat commented on the
divisiveness in the process of developing DSM-V.  This is evident
in the pages of the Psychiatric Times.  After Frances'
article came out, the president of the APA, along with other
dignitaries, wrote a rejoinder the following week ( href="http://www.psychiatrictimes.com/display/article/10168/1425806">Setting
the Record Straight: A Response to Frances Commentary on DSM-V). 
It is not pretty.  In fact, it is downright unprofessional.



The authors make some poorly supported claims.  In response to
charges of secrecy in the development process, they claim that the
process is more open than it was for prior editions.  That is
true, but misleading.  They set up pages where the leaders of the
various terms could write posts about the progress.  That was a
step in the right direction, but it has been done poorly.  The
people doing it are not bloggers, and not journalists.  They don't
write very often, and what they write tends to be uninteresting. 
It would have been much more effective to have blogger/journalists
cover the action.



What is more disturbing is that the authors include an allegation that
Frances is motivated to undercut DSM-V, because he still gets royalties
from DSM-IV.  I don't know how much he is getting, but I seriously
doubt it is a factor.  That is merely an ad hominem
attack, not something that has a place in serious medical
discourse.  The Psychiatric Times set up a "Topic Center"  href="http://www.psychiatrictimes.com/dsm-v">page that has links
to the other articles on the controversy.



You can go to www.dsm5.org to see href="http://www.psych.org/MainMenu/Research/DSMIV/DSMV/WorkGroups.aspx">who
is on the various workgoups, make href="http://www.psych.org/MainMenu/Research/DSMIV/DSMV/MakeaSuggestion.aspx">suggestions,
and view the href="http://www.psych.org/MainMenu/Research/DSMIV/DSMV/Timeline.aspx">timeline
for development.  There is a prominent link to a page, href="http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/TaskForceReports.aspx">Current
Activities: Report of the DSM-V Task Force, but it was last
updated in September 2008!   There are other updates, but
they are not easy to find.  If you poke around, you can find a
page of href="http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx">updates
from April 2009. 



To their credit, the committee has reached out to a wide variety of
relevant groups.  This includes the National Institute on Drug
Abuse (NIDA), the National Institute on Alcoholism and Alcohol Abuse
(NIAAA), the World Health Organization (WHO), the American Psychiatric
Institute for Research and Education (APIRE) and the World Psychiatric
Association (WPA).  All are involved in the process.  So it
is not exactly secret, but it could be (and should be) much more
open. 



Unlike others who have commented on the process, I doubt that the
acrimony -- as bitter as it has gotten -- poses a threat to the field
of psychiatry.  In fact, there was considerable acrimony when
DSM-III was developed.  This is detailed in an interesting piece
in The New Yorker, href="http://www.newyorker.com/archive/2005/01/03/050103fa_fact?printable=true">The
Dictionary of Disorder: How one man revolutionized psychiatry. 
I was still in college when DSM-III came out, so I wasn't following the
process.  But I did pay attention to DSM-IV, and I knew people who
were involved (at least peripherally).  I can say that there was
plenty of controversy then, as well.  But the field survived,
without any major schisms.  In fact, I tend to think that DSM-III
eventually contributed to the resolution of a pre-existing schism, that
between the psychodynamic and the biological psychiatry schools of
thought.  (Investigating that hypothesis would be a difficult but
enlightening challenge for medical historians or journalists.)



I'm sure there will be some bruised egos and hard feelings over the
process of developing DSM-V, at least on the academic side of the
field.  But that is an occupational hazard in academia.  On
the part of the practitioners, there will be squabbles, but nothing
major.  Practitioners are too busy to get all wrapped up in
this.  For the most part, the experienced folks will just keep
doing wha they are doing, for better or for worse.  The newer ones
will calmly accept it as part of the landscape in which they practice.