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December 2, 2011 6:17 AM   Subscribe

In DSM 5- 'Living Document' or 'Dead on Arrival', Allen Frances, chair of the DSM-IV development committee details some of the problems with the DSM-5 development process and alludes to some of the current controversies. The post is part of his ongoing series DSM-5 In Distress.

The DSM-5 is scheduled for publication in 2013. There has been considerable controversy of both the proposed changes and the process of the DSM-V committee. Recently the Society for Humanistic Psychology (Division 32 of the APA) (and the Coalition for DSM-5 Reform) has expressed it's concerns about the process in an Open Letter, as has the 120,000 member American Counseling Association(PDF) (APA response (PDF)). The DSM-5 committee responded (PDF) to the Open Letter, and Division 32 responded to that response. (Unfortunately, the Open Letter itself seems to have disappeared from the web. It was previously at this link.)

DSM-5 Watch aggregates much of the news around DSM-5.

With one in five American adults now taking a psychiatric medication, changes to the DSM will have wide ranging implications.

(Previously, Previously)
posted by OmieWise (37 comments total) 21 users marked this as a favorite

 
DSM 5 is the next (fifth) edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders
posted by bhnyc at 6:53 AM on December 2, 2011 [4 favorites]


Doesn't most of the controversy boil down to this version of the DSM being far more qualitative than quantitative in terms of making a diagnosis?

I mean, this isn't a revision of definitions solely. It's a revision in HOW diagnosis is made. Of course that's going to come with a lot of controversy and upset. And, yes, it's going to have far-reaching consequences, but the DSM-IV in all its revised forms wasn't always up to the task of successfully placing people in a diagnosis, either.
posted by zizzle at 7:13 AM on December 2, 2011


So DSM5 is like Windows Vista?

(But this is interesting. I had no idea there was so much controversy around this version.)
posted by benito.strauss at 7:19 AM on December 2, 2011


its hard to imagine the APA assembling a product that would lead to overdiagnosis of mental illness....
posted by dongolier at 7:24 AM on December 2, 2011


Of specific interest is the ADA's proposal to change the basic definition of a mental disorder and their rationale. This would indeed be a sweeping change; by removing clinical significant distress from the criteria, there is little question that there would be substantially greater diagnosis of mental disorder.

Frances addresses why clinical significance is important here.
posted by eschatfische at 7:44 AM on December 2, 2011


zizzle: "Doesn't most of the controversy boil down to this version of the DSM being far more qualitative than quantitative in terms of making a diagnosis?"

That's always been a criticism of the DSM. DSM-III and DSM-IV were seen as moving away from that trend, as permitted by properly-designed, peer-reviewed scientific studies, which if anything, has been the primary driver for making revisions to the DSM at all.

The accusation being made is that DSM-V is a regression from this approach. Based on the points outlined in the open letter, I'm strongly inclined to agree that the basis for a great degree of the DSM's current content and proposed future content is pseudoscientific at best.

Yes, qualitative criteria are a necessary evil in psychiatry, but the revisions are incredibly troubling, and seem to provide a great deal of leeway that would allow almost any member of the public to be "diagnosed" with a wide range of major conditions for which no physical basis, cause, or diagnosis exists.

Heck. Look at the definition for Oppositional Defiant Disorder. I challenge you to find any child on the planet who does not meet those criteria, let alone the reduced criteria proposed under DSM-V. This isn't science, and in practice has the potential to do a whole lot of evil, even when used in good faith.
posted by schmod at 7:45 AM on December 2, 2011 [6 favorites]


Psychiatric diagnosis is inherently political because it's essentially about deciding where the lines between "normal" and "abnormal" behavior should be drawn, and so this sort of thing happens with pretty much every version of the DSM.

At one point, there was a huge battle about whether homosexuality should be considered a mental disorder. Thinking on that has evolved pretty much alongside the trend toward greater acceptance in society over the past 50 years or so. And that gradual, sometimes contested process was reflected in the DSM. At first it clearly was. Then - until this was finally done away with in one of the versions of DSM III - you had "ego-dystonic" homosexuality, which basically meant if you were upset about being gay, then it was a disorder, but if you were comfortable with it, then it wasn't.

Here's a bit more history. I imagine all the contentiousness that surrounds these things is why they decided on a closed process this time around. But it's still a horrible idea and it's not very surprising that people are raising hell.
posted by Naberius at 7:47 AM on December 2, 2011 [1 favorite]


The DSM should really only be used recreationally.
posted by fuq at 7:52 AM on December 2, 2011 [8 favorites]


It seems like an overreach to conclude that people will be getting more drugs shoved down their throats simply because a new diagnostic manual seeks to refine the classifications of disorders and syndromes.

Psychiatry seems to be about helping people reduce suffering. If a new manual shifts the framework a bit and allows practicioners to notice that their previously intractible patient is actually suffering from a previously unrecognized form of X Disorder, that would seem to me to be a net good. Now the patient has a better chance at being helped.

Changing the book doesn't change the conditions people are suffering from. It only changes the framework. Wouldn't it be nice if they could sort out things like depression into a different framework that led to more appropriate treatments for the specific type of depression people suffer from? Perhaps it would reduce the volume of people we all see who are never helped by any drugs, but for whom CBT worked great? And vice versa, the people who weren't believed to be suffering from a chemical disorder and just forced to endure endless therapy to no benefit?
posted by gjc at 7:55 AM on December 2, 2011 [4 favorites]


Of specific interest is the ADA's proposal to change the basic definition of a mental disorder and their rationale. This would indeed be a sweeping change; by removing clinical significant distress from the criteria, there is little question that there would be substantially greater diagnosis of mental disorder.

Frances addresses why clinical significance is important here.
posted by eschatfische at 7:44 AM
My counter-rationale would be that the current threshold is too high. (For many disorders, mental and physical.) Nobody likes going to the doctor with a complaint, getting a workup and then being told (effectively) "you are only 10% depressed, suck it up." Or "well, you meet the criteria for depression, but because you didn't say the magic words ("seriously affecting my life"), I can't do anything for you."

This is something seen all the time with thyroid problems. If a patient is just on the normal side of the threshold, they have to tough through their condition no matter how difficult it is. But a couple of points on the other side, even if they actually notice fewer symptoms, are allowed to get treatment.

Suffering is suffering, and moving to a more qualitative approach seems like a good thing for patients. This is what is being done with physical ailments like diabetes, because doctors recognize that the effects are cumulative. Isn't it the same with many mental disorders? How many people live lives clouded by (as currently defined) sub-clinical disorders, who could be helped? I know a LOT of people who are edge cases like that, and the negative effects are numerous.
posted by gjc at 8:16 AM on December 2, 2011 [2 favorites]


Was there this much of a shit storm when DSM-IV, DSM-III, II, or I came out? Are people just more likely to storm the shit these days?
posted by Blake at 8:16 AM on December 2, 2011


I am waiting for the edition which includes "Obnoxious Asshole disorder" characterized by being loud, pushy, aggressive, over-confident, ignorant and proud of it, always trying to sell you something, and harboring an obsessive need to appear normal in a consumer society. Must love football and follow sports if male, reality TV, and if female, conversations about housework. Endless tasteless discussions of cruises taken can also be a symptom.

Funny how so many "disorders" are just people on the more introverted, geeky end of the spectrum of personalities, and so few are about the extroverted and obnoxious who make others miserable.

Not every way of being is a mental illness except a very narrow band of bland "normal". And characterizing children with many of these dubious diagnoses can be dangerous and soul-stifling. Ans as previous posts have mentioned, much of it is pseudoscience. Junk the whole book and get back to verified mental conditions as determined by real peer reviewed science, not every self-help fad and "illness" that comes along.
posted by mermayd at 8:22 AM on December 2, 2011 [9 favorites]


Psychiatry seems to be about helping people reduce suffering. If a new manual shifts the framework a bit and allows practicioners to notice that their previously intractible patient is actually suffering from a previously unrecognized form of X Disorder, that would seem to me to be a net good. Now the patient has a better chance at being helped.

Well, the criticism is that the new diagnoses do not have enough research backing to be recognized as such. The criticism is being made by people whose careers are predicated on "helping people reduce suffering." The suggestion here is that the DSM5 has actually lost that focus.

Suffering is suffering [...]Isn't it the same with many mental disorders? How many people live lives clouded by (as currently defined) sub-clinical disorders, who could be helped? I know a LOT of people who are edge cases like that, and the negative effects are numerous.

It isn't really the same, no. For one thing, there are no objective physiological diagnostic tests for mental disorders as there are for physical disorders. Psychiatry rests on qualitative description of phenomenology. The process by which changes are made to diabetes treatment, say, are research driven. The criticism here is that the DSM-5 is being set up to drive research, rather than being based on already extant robust research, and rather than to help with patient care. And as nice as a "suffering is suffering" position sounds in theory, it's really problematic in practice, since the vicissitudes of daily life include suffering. Non-pathological suffering is part of the human experience. That doesn't make it good, or laudatory, but it does make it, by definition, non-pathological. The criticism being levied here is that the DSM-5 goes too far toward pathologizing normal human life and behavior, which is problematic for all kinds of reasons. Now, one might argue that everyone should be allowed to be "extra good" by taking psychotropic meds, say (better living through chemistry), but that's a different argument than one that suggests that we change the criteria by which we assess people as mentally disordered.

Finally, I question whether or not there is a lot of sub-clinical mental illness around for which people are seeking treatment but being denied. I'm sure there's some, but, honestly, 20% of the US population is on psychotropics, and that does not count people who are in therapy but not on meds.
posted by OmieWise at 8:46 AM on December 2, 2011 [4 favorites]


With this wide a gap between the direction of the DSM-5 Committee and the views of numerous practitioner and research communities, it seems rather clear that pharmaceutical industry money has something to do with where the DSM-5 is going.
posted by parudox at 9:10 AM on December 2, 2011


So DSM5 is like Windows Vista?

It reprograms the social code.
posted by kuatto at 9:12 AM on December 2, 2011 [1 favorite]


Was there this much of a shit storm when DSM-IV, DSM-III, II, or I came out? Are people just more likely to storm the shit these days?

I don't know if there was as much of a shit storm, but I truly believe there should have been. The DSM has been open to serious criticisms for a long time, hell half the people who wrote the DSM 4 had direct financial ties to the pharmaceutical industry.

Not to mention the whole pathologicalization of the human condition issue that dogs our modern medical models in general. I am by no means a medical luddite but sometimes the direction we seem to be heading makes me want to bang my head against the desk repeatedly and hard.

In Humanizing Madness Niall McLaren argues pretty strongly that the DSM is fundamentally flawed because the categories it creates has no basis in a scientific model of mental illness, and it lack reliability because different diagnosis share similar criteria and even different criteria can oftentimes just be rewording of the same ideas, thus a decision to allocate one diagnosis over a different diagnosis (and thus a different treatment regimen) is merely a matter of personal preference or prejudiced of any given doctor.
posted by edgeways at 9:23 AM on December 2, 2011 [2 favorites]


"It's a revision in HOW diagnosis is made.". . .

. . .for STATISTICAL purposes. This will not have much direct effect on how diagnosis for treatment purposes. The DSM is an important and useful document but I think there's a lot of misunderstanding of the way its used by psychiatrists.

I'm typing without double checking references, but I know the original intent of the DSM was to facilitate communication and research by codifying the language with which Doctors and Counselors described mental health issues. For doctors I've worked with (I have limited exposure though, I will admit) its still treated as such. Doctors might consult a DSM for fine points of documentation (along the lines of differentiating I dunno, atypical and typical bereavement and acute adjustment disorder) but treatment decisions should be another line of thinking made upon existing research, the clinical picture and the doctors experience.

I will tell you no psychiatrist I ever met upon meeting a patient will base the decision to medicate based on what the DSM says - that's not the DSM's role. (A fact that causes a good deal of confusion among students who are like - 'sir, why did you make the diagnosis of Major Depressive Disorder, he only meets 4 of the 9 criteria?' Dr X: 'Put down that stupid DSM and look at the patient.'
"Heck. Look at the definition for Oppositional Defiant Disorder. I challenge you to find any child on the planet who does not meet those criteria, let alone the reduced criteria proposed under DSM-V. This isn't science, and in practice has the potential to do a whole lot of evil, even when used in good faith."
Well, I have met literally hundreds of children who don't meet that criteria. Actually, of the dozens of children I've met in inpatient child psych wards and numerous other psych issues handed on outpatient basis, I've encountered ODD on the order of single digits. No offense, but it actually does take training to understand what the DSM means by "often loses temper" isn't a kid crying when he's told to go to bed, but a child who has practically ZERO age appropriate coping mechanisms. This is why the DSM does not supplant clinical judgement and why WebMD does not make the best diagnostician. Yeah its a judgment call even with guidelines and training and research, but just because there's no blood test for depression doesn't mean the current frame work "isn't science."

I know there's a lot of good reasons to be cautious when it comes to medical treatment of mental health, I am personally among the least medication gung-ho people I know. And I am aware that the upcoming DSM-V is a contentious update, no doubt largely due to the scope of changes but also likely some real conflict with existing methods of diagnosis that are still helping patients. I apologize I didn't go to deep in the links, I just didn't want the DSM to be given importance it doesn't (and was never meant to) have.
posted by midmarch snowman at 9:24 AM on December 2, 2011 [10 favorites]


The problem, IMO is that the DSM doesn't seem all that scientific. It's like: you can have a geology book that you can use to identify minerals based on various properties, but you also have an underlying molecular structure. You can look at a plant's leaves and flowers to identify it, but you can also look at the underlying DNA.

We know how rocks are formed, and how DNA works, but with psychology we still really don't know much about how the brain works on a 'macro' level, we know how neurons and stuff like that work -- if you can pinpoint a molecular or cellular cause, a sufficiency of some neuro-structural issue it makes sense to diagnose it.

But if you look at the ODD one, for example it's just a list of questions, not even quantitative ones. It's just personality judgments. And worse, ones that are going to be hugely biased based on your opinion of someone. If you don't like a kid you're going to be much more likely to answer 'yes' on those questions then if you do.
posted by delmoi at 9:43 AM on December 2, 2011


It seems to me that a lot of the criticism from laypeople stems from an internalized stigmatization of "mental disorders." They prefer informal terms like "shyness" to diagnoses like "social anxiety" because they place so much value on NOT being "disordered." I think that if people get passed the stigmatization, then they'll see that turning "normal," albeit detrimental to the patient, personality traits into diagnoses is actually a large step towards helping the patient.

It should be noted that I am specifically not addressing the criticism that the DSM-V is not scientific enough as I don't know anything about that.
posted by callmejay at 9:46 AM on December 2, 2011 [3 favorites]


As a scientist, the DSM-IV comes across as a badly thought out research proposal from an undergraduate. The oppositional defiant disorder brought up above is a good example. The criteria for diagnosis:

Diagnostic criteria for 313.81 Oppositional Defiant Disorder

A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:
(1) often loses temper
(2) often argues with adults
(3) often actively defies or refuses to comply with adults' requests or rules
(4) often deliberately annoys people
(5) often blames others for his or her mistakes or misbehavior
(6) is often touchy or easily annoyed by others
(7) is often angry and resentful
(8) is often spiteful or vindictive
Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.

D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.


Okay, seriously. Count 'em up lists for diagnosing are bound to fail. Any four of these? These are supposed to be independent variables? Because it seems if you have one like "often argues with adults" you are almost certainly losing your temper, you are probably defying adults' requests, could be termed "annoying," "spiteful or vindictive," and/or "angry and resentful." One can get you six. Now I suppose you could come up with a weighted system of totaling that reflected intensive research in the matter, but hey, that would take the voodoo out.

And I'm not a strict behaviorist, but how about listing behaviors that evince "anger and resentment" rather than determining the child is angry above normal spanning at least six months?

Lasting 6 months? It happened once 6 months ago and recently or you've had X number of episodes in six months (again of specific behaviors).

B is a good criteria. It causes clinically significant impairment in functioning. But this is the one you need to spell out.

C and D just say the behaviors don't fall into some other DSM pit.

Now, pathologically defiant children can exist. However, this pseudo-scientific undefined melange of symptoms doesn't help identify them any more than instinct (which is not worthless).
posted by dances_with_sneetches at 9:48 AM on December 2, 2011 [2 favorites]


midmarch snowman--I'm really confused by your comment. I'm a clinical social worker, I have a private practice, I teach Master's level social work classes, including psychopathology, and I work in public mental health administration. The DSM, and the diagnoses it describes, is central to each of those endeavors. It's true that the place I use the DSM the least is in clinical practice. It's important for providing information to insurance companies, but for nothing else in how I work with patients. On the other hand, all of the psychopathology textbooks I use are predicated on the DSM, comprehensive exams in my department reference the DSM, and the licensing exams for clinical social work reference the DSM. In public mental health DSM diagnoses are required, collected, analyzed, and used to determine benefit levels and requirements. Sure, clinical considerations have a huge role in all of those things as well, but it displays a substantial lack of familiarity with how deeply embedded the DSM is in the mental health care system in the US to suggest that it's primarily a research tool.

Here are the first couple of sentences from the DSM-IV introduction:
This is the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV. The utility and credibility of DSM-IV require that it focus on its clinical, research, and educational purposes and be supported by an extensive empirical foundation. Our highest priority has been to provide a helpful guide to clinical practice. We hoped to make DSM-IV practical and useful for clinicians by striving for brevity of criteria sets, clarity of language, and explicit statements of the constructs embodied in the diagnostic criteria. An additional goal was to facilitate research and improve communication among clinicians and researchers. We were also mindful of the use of DSM-IV for improving the collection of clinical information and as an educational tool for teaching psychopathology.[emphasis added]
Note that research is an "additional goal."

Again, in the intimate clinical interaction the DSM is largely not present, but it frequently frames that interaction in very concrete ways. Part of the criticism levied by Allen Frances above (and he should know the DSM pretty well, he chaired the DSM-IV committee) is that if the DSM-5 is issued as it currently stands, people will stop using it entirely.
posted by OmieWise at 9:49 AM on December 2, 2011 [2 favorites]


And reading midmarch snowman. Virtually every psychiatrist I have met uses the DSM-IV to diagnose and suggest treatment. I've had it read verbatim to me regarding cases.
posted by dances_with_sneetches at 9:51 AM on December 2, 2011


If they tried to make a statistical model for every disorder recognized in the DSM V they'd never finish. Then, when they put out a half-assed unfinished version, they would discover that other models have already superseded their own in every field of experimental research.

Statistical models are better for diagnosing people, and if you can find a psychiatrist who uses those, that's a better psychiatrist than most people get. Statistics are also finicky and difficult and it's difficult to get much with a diagnosis of 71% Autistic.

I guess if we must use vague, over-broad, ambiguous, misleading labels for mental disorders, and therefore must risk mis-diagnosis, medical malpractice, stereotyping, and ableism, it's probably for the better that the labels are standardized somehow or other.
posted by LogicalDash at 10:17 AM on December 2, 2011


(For anyone interested in further reading, it seems as though the open letter link is working again!)
posted by Keter at 10:25 AM on December 2, 2011


Count 'em up lists for diagnosing are bound to fail. Any four of these?

This is also very evidently an issue with the criteria for borderline personality disorder. Diagnosing someone with BPD even if they don't self-harm or have unstable relationships is possible. Ridiculous, but possible.
posted by the young rope-rider at 10:26 AM on December 2, 2011 [1 favorite]


I had the DSM when it was in beta.
posted by pwally at 10:40 AM on December 2, 2011


Psychiatry seems to be about helping people reduce suffering.

Not anymore.

DSM-IV defines mental illness as something that causes includes "clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)" as part of the definition of mental illness.

DSM-V includes neither of those criteria. It tells us that mental illness means "a behavioral or psychological syndrome or pattern that occurs in an individual that is based in a decrement or problem in one or more aspects of mental functioning." Perfectly content people who are functioning well in society are made candidates for treatment by this change.
posted by justsomebodythatyouusedtoknow at 10:53 AM on December 2, 2011 [4 favorites]


I think that if people get passed the stigmatization, then they'll see that turning "normal," albeit detrimental to the patient, personality traits into diagnoses is actually a large step towards helping the patient.

The problems with this are that:
1) people are not past the stigmatization. And with things still happening like depression diagnoses upping people's life insurance premiums it doesn't seem like that's something that's going to happen in this lifetime.

2) Pathologizing personality traits means that, yes, maybe more people who need it will receive treatment, but also a whole lot of people who don't need it will be forced into treatment, which in my mind is equally damaging. It's essentially telling people who we would say now fall into the "normal" range of variation in traits and behaviors, "You are disordered. There's something inherently wrong with how you think.", which is damaging in and of itself. Then add to this the social stigmatization of mental illness, and things become even more problematic.

As a student in a counseling program I've heard quite a bit about the DSM-V recently, and none of it good. At this point there's especial uproar over the proposed removal of "bereavement" as an exempting factor in the clinical depression diagnosis criteria. The new DSM would be pathologizing grief, a normal, healthy human experience. Somewhere this revision process jumped the rails.
posted by clavier at 11:06 AM on December 2, 2011 [1 favorite]


It seems to me that a lot of the criticism from laypeople stems from an internalized stigmatization of "mental disorders." They prefer informal terms like "shyness" to diagnoses like "social anxiety" because they place so much value on NOT being "disordered."

How about when any gender identity other than cis is a "mental disorder" or a sexual perversion? When some of the text completely misunderstands the entire thing and decides that some biological males who have a female or non-binary identity are simply gay, and that biological females simply never have a male identity? That's the kind of crap that was at least proposed for this edition, though I know there was some fighting over it.
posted by Foosnark at 11:23 AM on December 2, 2011


Funny how so many "disorders" are just people on the more introverted, geeky end of the spectrum of personalities,

While I may agree with some of your broader points, you must have mighty thews indeed to draw such an incredibly long bow. I think categorising what can be very debilitating - albeit controversial - disorders as akin to personality traits is flirting very closely to trivialising mental illness.
posted by smoke at 11:25 AM on December 2, 2011


I wonder how many people with the conditions being so 'expertly' described where involved in the writing of the book? Oh wait I have a sneaking suspicion about that.
posted by edgeways at 11:54 AM on December 2, 2011 [1 favorite]


As a scientist, the DSM-IV comes across as a badly thought out research proposal from an undergraduate. The oppositional defiant disorder brought up above is a good example.

I can assure you that oppositional defiance disorder does exist, and it is often co-morbid with depression and anxiety. I find it interesting that some people who tout science here have made snap judgments about the DSM, without THOROUGH reading, and or clinical experience. Is that science? Please.

ODD, for example, is a persistent pattern of behavior, as described in DSM, over a period of months. I have known kids like this, and they are hell on earth to live with, and treat. It's pretty well known that treating kids like this can also stress a good therapist, because the kids are habituated to defiance. Often, environmental stresses are to blame (broken home, early separation anxiety, poor discipline patterns, etc. etc.) - or partly to blame. Certainly, there is probably a genetic component as well, and as time goes on we will know more about that.

Anyone who doesn't have experience in physical medicine, for example, can go through a clinical manual and start imagining that they have symptoms of many diseases. It takes a trained therapist (and a good one, at that) to determine what the root causes of suffering are, and treat them appropriately. I see a lot of "science-related" criticism coming from just that kind of reader, on this thread. That's unfortunate, and as far from a "scientific" approach to these things as one can get. Science itself is self-correcting. Making the general assumption that the DSM isn't, or never will be, isn't very "science-like".

What bothers me is not DSM, but rather the failure of the psychiatric profession to tale a more holistic look at mental functioning from a framework of diet, stress, and other incidental factors that are present in our culture.

For instance, Andrew Weil has just written a book, about how to generate whatever it is we call happiness, with sound suggestions that are all backed up by well-referenced research. Why don't we see more of this stuff impacting the DSM series. That's the problem.
posted by Vibrissae at 12:25 PM on December 2, 2011 [1 favorite]


DSM-V includes neither of those criteria. It tells us that mental illness means "a behavioral or psychological syndrome or pattern that occurs in an individual that is based in a decrement or problem in one or more aspects of mental functioning." Perfectly content people who are functioning well in society are made candidates for treatment by this change.
I don't have a problem with that personally, but then why call it an illness? Why not just a "mental demographic cluster"?

This obviously fits in with the theory that drug companies are behind all this stuff. I mean, if we say someone is "Shy" or "Fits with the shy statistical cluster" what's the justification for giving them medicine? Personally, I don't have a problem with it if an individual wants to take a pill that makes them more outgoing (provided it's not too addictive, doesn't have too many side-effects, etc) but in today's society that would be considered "recreational drug abuse".

I think any time you have 'science' where the results themselves have huge impacts in people's lives it's going to get really distorted. If you look back at the whole 'is Pluto a planet' that was really a sort of political decision, scientists found a planet larger then Pluto and if they called Pluto a planet, they would have to call that a planet too. Ultimately they just decided to drop Pluto. But that didn't affect anyone's life (and people still got upset). But if you do that with a disease it's suddenly going to be an even huger issue. So you end up with a really messed up end result.
ODD, for example, is a persistent pattern of behavior, as described in DSM, over a period of months. I have known kids like this, and they are hell on earth to live with, and treat. It's pretty well known that treating kids like this can also stress a good therapist, because the kids are habituated to defiance.
Sure, but couldn't there be a lot of different underlying causes for that kind of behavior? Kids could be normal and just have shitty parents who only respond when they throw tantrums, maybe they have neurological problems, who knows?

The other problem is that it does not seem very scientific. It's like, if you're deciding if something is a planet or not you can just measure the weight. If you want to know if someone is obese, you do the same thing, and compare it with their height. If you want to know if someone has high blood pressure you get a number.

But with ODD those 'measurements' are very subjective sounding. The argument "well if you're a psychologist you know how to measure those things correctly" doesn't really seem very 'scientific'. It's not even like "in the 90th percentile of having a short temper" -- and if you did it that way you'd have the issue of an arbitrary cutoff.
posted by delmoi at 1:47 PM on December 2, 2011


So I base my comments based on what I received from the psychiatry professors and pediatricians I've worked with at exactly two inpatient centers in one town, which is to say my experience is limited and not exactly broad. I have no real credentials, but that's what was stressed to me. I will freely admit that psychiatry is not my path, and am open to any better explanation from another better qualified MeFite but I just wanted to make the point early in this thread that if the DSM changes criteria, Dr. Headshrink will not cull through his patient rolls, decide a bunch of people who the DSM used to say were Dysthymic are now Atypically Depressed, and call them all up to prescribe zoloft. The DSM is very important but for clinical and prescribing decisions I think its easy to overstate its importance.
"In public mental health DSM diagnoses are required, collected, analyzed, and used to determine benefit levels and requirements"
I apologize if I stepped on any toes. I don't want to say the DSM is a akin to a dictionary and of little relevance, but its the type of uses like this, OmieWise, that I'd describe as 'diagnosis' for statistical purposes. I kinda just made up the distinction, I suppose, but it helps me make sense of the differences in what I see written down in books and paperwork, and what I see in hospitals. I'm still learning and not teaching yet, but it makes sense to me.

For another example of what I mean, in the more medical side of things, consider SIRS criteria. A quick inelegant explanation: SIRS is state defined by the presence of two out of four criteria [count-'em-up-lists dances_with-sneetches! Docs are Rife with them!]. The criteria suggest an inflammatory response, basically you body may be gearing up your immune system. SIRS is related to Sepsis, in that when a patient has SIRS, and there is also suggestion of an infection (for example, a sore throat or cough suggesting respiratory infection or painful urination suggesting a UTI) the patient can, by definition, be diagnosed with Sepsis. Its accepted that SIRS is super useful for population level analysis of hospital patients or patients with shock. Its actually helped revolutionize the treatment of Septic shock in the emergency room.

BUT if you clicked on the link you saw that SIRS criteria includes basic stuff like "heart rate over 90 beats per minute" or "temp under 37 degrees." Yup, you can pretty much walk onto any given hospital floor and close to 90% of the patients and half the nurses may meet SIRS criteria. Some person may have a resting heart rate of 92 and a oral temp of 96.7 and meet the criteria. If they cough up some good, gross phlegm, they now could be said to have Sepsis depending on how the observer was trained. But that's more for documentation or record keeping to statistical analysis purposes. Are Doctors going to run into the room and start IV fluid boluses and antibiotics? Probably not, cause SIRS is good for raising red flags but its not how clinical, treatment-oriented diagnostic decisions are made.
"all of the psychopathology textbooks I use are predicated on the DSM, comprehensive exams in my department reference the DSM, and the licensing exams for clinical social work reference the DSM"
Again, I'm sorry if I stepped on any toes, I don't want to suggest clinical mental health workers don't use the DSM. It is a very useful reference. The US Medical Boards as well certainly reference DSM criteria, but again, as more of a framework than as holy writ. For example, my training never stresses recalling specific criteria (thank god, btw, because some of those, like for classically defined Autism, go on forever), but focused on paradigms that it contains (e.g. the presence of a single manic episode precludes the diagnosis of depression in favor of some sort of bipolar disorder... I think... it's been a while).
posted by midmarch snowman at 1:47 PM on December 2, 2011


And reading midmarch snowman. Virtually every psychiatrist I have met uses the DSM-IV to diagnose and suggest treatment. I've had it read verbatim to me regarding cases.

So, I apologize, my language was unclear. I am obviously inexpert in describing the role of the DSM in treatment choices, so let me just describe a typical experience I had. A woman admitted for self inflicted wounds had a very troubling psychiatric medical history that was long and difficult to parse. Given the persistence of the behaviors you could make a case for Borderline Personality, Bipolar with psychotic breaks, or shizoaffective disorder or some amorphous progression that may have at one point involved all three.

The psychiatry attending arrived at that diagnosis by keying in on salient features of her disease that could be cut up and made to fit DSM criteria or textbook descriptions, but were also informed by his experience and the intangible presenting features of the patient - no one sat at a table stroking their chin and thinking "if I classify this behavior to meet criteria (1)(c) its Schizoaffective but if I classify another way there's more criteria for Bipolar Disorder. " The bottom line, the patient was most likely going to benefit from a trial atypical antipsychotic and serious inpatient therapy, but no one busted out the DSM and checked boxes to make a diagnosis, they wrote down Psychotic Disorder Not Otherwise Specified and delayed making a super official diagnosis until there was more information on what therapy helped her best.

-------------------

I guess all I was trying to say is, yeah, everyone uses it to learn the salient features of the different ways a brain could be sick, everyone uses it in presentations and communication and reports to structure their decision making process, but I never saw it used on rounds as a checkbox rubric. The women in story got atypical antipsycotics because all of the Docs training in experience told him it was the best choice in that setting, not based on the DSM alone. There's no danger of the DSM-V coming out and a doc saying "I used to have great success giving Seroquel in this situation but now I have to classify this as something else and the DSM is forcing me to give you lithium," which seems to be the role or importance some lay people assume the DSM has.
posted by midmarch snowman at 1:49 PM on December 2, 2011


delmoi: But with ODD those 'measurements' are very subjective sounding. The argument "well if you're a psychologist you know how to measure those things correctly" doesn't really seem very 'scientific'. It's not even like "in the 90th percentile of having a short temper" -- and if you did it that way you'd have the issue of an arbitrary cutoff.

That's right, they are "subjective-sounding". ALL diagnoses/treatments for illness (mental or otherwise) are subjective. Medical treatment is a moving target. It takes more than correlating symptoms from DSM to make a diagnosis. That's what trained therapists and psychiatrists are for. Psychiatrists - the good ones - are damn well better equipped to diagnose mental illness than non-mental health professionals. Is the DSM overused and leaned on too much by some therapists? Yes. Is the DSM the "cause" of bad treatment? No.

If you doubt what I said above, about ODD kids, go try to live with one, or treat one - along with all the co-morbidity that accompanies real ODD. It's a nightmare - both for the sufferer, and those s/he lives with. Is ODD over-diagnosed? Yes, probably. Is that DSM's fault. No.

There are good auto mechanics and bad auto mechanics; we don't blame the repair manuals. DSM is ONE tool toward aiding diagnosis and treatment. The end goal is to remove bottlenecks to mental health, or treat in one way or the other.
posted by Vibrissae at 3:31 PM on December 2, 2011


The DSM-5 is not the end of the world as some claim it to be.

You can't help but wonder if Allen Frances has some sour grapes about the process, given he was the chair for previous version, but not this one.

The DSM-IV process was conducted largely pre-Internet, and therefore had very little public feedback and even less transparency. In many ways, while the DSM-5 process has been a little bit more "closed door," it's the first revision that's actually been open to widespread public comment via their website.

This is an unprecedented development in the history of a scientific reference manual.

As for the science behind it... well, there will always be diagnoses that have less science than others. I'm sure we could go back to the DSM-IV and find a handful of diagnoses where the workgroup approved a change or inclusion of the diagnosis with a threshold of evidence that didn't come close to other diagnoses like depression.

Some people always want things to be better or more ideal than they are. But in the real world, we have limited resources and time. DSM-IV came out in 1994 and by the time the DSM-5 is released, it'll be nearly 20 years in-between major revisions. Given all that we've learned about mental health concerns in the past 2 decades, this is almost an unconscionable amount of time.

The DSM-5 won't be perfect, but it won't result in a 20% spike in mental diagnoses overnight either. It will be revised (just as the DSM-IV was in 2000), and that revision will be one step closer to something better...
posted by docjohn at 4:48 PM on December 2, 2011 [1 favorite]


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