Psychiatry Manual Drafters Back Down on Diagnoses
By BENEDICT CAREY
Published: May 8, 2012
In a rare step, doctors on a panel revising psychiatry’s influential diagnostic manual have backed away from two controversial proposals that would have expanded the number of people identified as having psychotic or depressive disorders.
Sam Hodgson for The New York Times
The current edition of the Diagnostic and Statistical Manual of Mental Disorders. The manual affects treatment, research and insurance.
The doctors dropped two diagnoses that they ultimately concluded were not supported by the evidence: “attenuated psychosis syndrome,” proposed to identify people at risk of developing psychosis, and “mixed anxiety depressive disorder,” a hybrid of the two mood problems.
They also tweaked their proposed definition of depression to allay fears that the normal sadness people experience after the loss of a loved one, a job or a marriage would not be mistaken for a mental disorder.
But the panel, appointed by the American Psychiatric Association to complete the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., did not retreat from another widely criticized proposal, to streamline the definition of autism. Predictions by some experts that the new definition will sharply reduce the number of people given a diagnosis are off base, panel members said, citing evidence from a newly completed study.
Both the study and the newly announced reversals are being debated this week at the psychiatric association’s annual meeting in Philadelphia, where dozens of sessions were devoted to the D.S.M., the standard reference for mental disorders, which drives research, treatment and insurance decisions.
Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and the chairman of the task force making revisions, said the changes came in response to field trials — real-world studies testing whether newly proposed diagnoses are reliable from one psychiatrist to the next — and public commentary. The psychiatric association has posted its proposals online, inviting public reaction. More than 10,500 comments have come through the site, many of them critical.
“At long last, DSM 5 is correcting itself and has rejected its worst proposals,” said Dr. Allen Frances, a former task force chairman and professor emeritus at Duke University who has been one of the most prominent critics. “But a great deal more certainly needs to be accomplished. Most important are the elimination of other dangerous new diagnoses and the rewriting of all the many unreliable criteria sets.”
The criticism of “mixed anxiety depressive disorder” was that it would unnecessarily tag millions of moderately neurotic people with a psychiatric label. Mixed states of depression and anxiety can be severe, but the proposed hybrid had looser criteria than either depression or anxiety on its own — lowering the bar significantly for a diagnosis.
The primary concern with “attenuated psychosis syndrome” was that it would lead to unwarranted drug treatment of youngsters. The diagnosis was meant to identify people, usually young, who exhibit psychosis-like symptoms and treat them early. But 70 percent to 80 percent of people who report having weird thoughts and odd hallucinations do not ever qualify for a full-blown diagnosis — and might be treated for something they did not have.
On the manual’s site, in blogs and other public forums, advocates, therapists, scientists and people receiving services sounded off on the proposed changes. The psychiatric association made an effort to listen, Dr. Kupfer said. The site “is not just a P.R. effort,” he said. “We’re getting feedback, and it all goes to the working groups.”
The proposed definition of autism, which would eliminate related labels like Asperger’s syndrome and “pervasive developmental disorder,” came under fire in January, when researchers at Yale University presented evidence that about half of the people who currently have a diagnosis on the high end of the “autism spectrum” would no long qualify under the new definition.
At this week’s annual meeting, researchers presented data from an unpublished study of some 300 children, finding that the proposed definition would exclude very few who currently have a diagnosis of autism or a related disorder.
But meeting attendees got mixed messages on autism. In a talk on Tuesday, Dr. Susan E. Swedo, head of the panel proposing the new definition, said that many people who identify themselves as “aspes,” for Asperger’s syndrome, “don’t actually have Asperger’s disorder, much less an autism spectrum disorder.” Dr. Swedo is a researcher at the National Institute of Mental Health.
The issue is hardly settled. Findings from published studies are conflicting, but three recent analyses provide support for the Yale estimate, and more papers in the pipeline are also documenting a significant reduction in numbers of those who would qualify under the new criteria. Getting such a diagnosis is critical to obtain state-financed services for children with special needs.
“I certainly hope the D.S.M. task force is right, that the numbers won’t change much,” said Dr. Fred R. Volkmar, director of the Child Study Center at the Yale School of Medicine and senior author of the study presented in January. But if the new definition does not change who gets a diagnosis, he asked, “Why mess with it at all?”The D.S.M. panel also made an attempt to clarify the difference between normal sadness and depression, by spelling it out in a footnote added to the proposed depression definition.
The note reads, in part, “The normal and expected response to an event involving significant loss, including feelings of intense sadness, rumination about the loss, insomnia, poor appetite and weight loss, may resemble a depressive episode” but is not necessarily one.
Judging from the past year, the normal and expected response to most of these revisions will be more contentious disagreement that will most likely intensify over the coming weeks.
The psychiatric association send out reminders this week that the current — and final — period for public comment ends on June 15. The final draft of the manual is due at the printer at the end of the year and is scheduled for release in May 2013.
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Psychiatry Manual Drafters Back Down on Diagnoses - New York Times
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via psychiatry research - Google News on 5/8/12
 Scientific American (blog) |
Psychiatry Manual Drafters Back Down on Diagnoses
New York Times ... are being debated this week at the psychiatric association's annual meeting in Philadelphia, where dozens of sessions were devoted to the DSM, the standard reference for mental disorders, which drives research, treatment and insurance decisions. Newsflash from APA Meeting: DSM-5 Has Flunked Its Reliability TestsHuffington Post (blog) Science Remains a Stranger to Psychiatry's New BibleScientific American (blog) Most DSM-5 Revisions Pass Field TrialsMedPage Today Washington Post -Gawker all 20 news articles »
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Science Remains a Stranger to Psychiatry's New BibleScientific American (blog)
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Streams of Consciousness HomeAboutContactScience Remains a Stranger to Psychiatry’s New Bible
May 8, 2012|
 6
By Ferris Jabr*
Part 2 of a series In the offices of psychiatrists and psychologists across the country you can find a rather hefty tome called the Diagnostic and Statistical Manual for Mental Disorders (DSM). The current edition of the DSM, the DSM-IV, is something like a field guide to mental disorders: the book pairs each illness with a checklist of symptoms, just as a naturalist’s guide describes the distinctive physical features of different birds. These lists of symptoms, known as diagnostic criteria, help psychiatrists choose a disorder that most closely matches what they observe in their patients. Every few decades, the American Psychiatric Association (APA) revises the diagnostic criteria and publishes a brand new version of the DSM. The idea is to make the criteria more accurate, drawing on what psychologists and psychiatrists have learned about mental illness since the manual’s last update. 
The fat volume on top is still skinny on the science. Courtesy of Ferris Jabr.
In other words, the APA intended to make the DSM-5 the most scientific edition of its reference guide yet, which would be a real boon for a book that has been routinely lambasted as fiction borne out of convenience, rather than a solid clinical text grounded in research. Now, only one year away from the planned publication of the DSM-5, most psychiatrists have accepted that the APA’s initial optimism about informing revisions with cutting edge science is well intentioned, but premature. Most of the proposed revisions to current DSM criteria—many of which are genuine improvements—are based not on insights from genetics and neuroscience, but rather on clinical experience, prevalence studies and plain old common sense. Indeed, many of these changes could have been made years ago. (For more on these changes, see “Psychiatry’s ‘Bible’ Gets an Overhaul,” by Ferris Jabr, Scientific American Mind, May/June 2012.) Cutting and Collapsing Categories Consider, for example, that the DSM-IV organizes schizophrenia into six types, all of which the APA proposes eliminating from the DSM-5. Why? Because these archaic subcategories were never grounded in empirical research in the first place; they were just what sounded good to the DSM authors of yore. In truth, these ostensible types of schizophrenia probably do not exist. Similarly, the APA is nixing three of the 10 current personality disorders, essentially acknowledging that these were never legitimate illnesses in the first place. So many people fit the criteria for more than one personality disorder simultaneously that 10 varieties become superfluous. Likewise, the DSM-5 collapses four of the five current pervasive developmental disorders—including autistic disorder and Asperger’s—into a single category called autism spectrum disorders, because there is so much overlap in their respective criteria. None of these revisions are founded on recent revelations from genetics and neuroimaging research. Study after study has failed to discover a set of genes or unusual brain structures that reliably identifies major mental disorders. Rather, these are changes that many psychiatrists have been advocating for the past two decades based on their everyday clinical experience, studies of illness prevalence and the sense that some of the current criteria do not make sense. Despite awareness of these flaws, the APA did not get around to updating the DSM until now, the first substantial revision in 30 years. One exception to the APA’s disappointed ambitions to base the ongoing revisions on neuroscience are the proposed changes to addictions. Scientists understand quite a bit about how the addicted brain differs from a typical brain. The APA has proposed adding gambling disorder to the DSM-5, in part because reward circuits in the brains of gambling addicts light up in the same way as those in alcoholics and drug addicts. Still, some researchers worry that the DSM will end up sanctioning addictions to everything—gambling, sex, the Internet—shifting focus to what people are addicted to from why addictions form in the first place. Flaws in the Process 
Easing the pain of mental illness requires labeling it. Courtesy of breahn via Flickr.
In January of this year, David Elkins, president of the Society for Humanistic Psychology, authored an open letter to the APA calling for such independent review: “As you know, it is common practice for scientists and scholars to submit their work to others for independent review…Will you submit the controversial proposals in DSM-5 to an independent group of scientists and scholars with no ties to the DSM-5 Task Force or the American Psychiatric Association for an independent, external review?” [Emphasis theirs] In a letter of its own, the APA responded: “There is, in fact, no outside organization that has the capacity to replicate the range of expertise that DSM-5 has assembled over the past decade to review diagnostic criteria.” Recently, the APA has mentioned here and there that it has in fact created such a “scientific review committee,” separate from the task force, but you will not find any satisfactory description of it or its responsibilities on the DSM-5 Development website. Darrel Regier, vice-chair of the Task Force, explained that the committee includes about six scientists selected by the board of trustees, because “there is no way you can have truly independent review,” and declined to say more. Allen Frances, chair of the DSM-IV Task Force and the most outspoken critic of the DSM-5, says that the APA only created this group at the last minute in response to criticisms. “The scientific review committee is not even transparent,” Frances says. “They report confidentially to APA.” Frances and other critics have pointed to a related flaw in the ongoing revisions. Every time the APA revises the DSM, it conducts “field trials” of new diagnostic criteria. These are dry runs of the proposed revisions in clinical settings that test their reliability—that is, whether two different psychiatrists using the new criteria reach the same conclusion about a given patient. Since 2010, the APA has been conducting field trials for the proposed DSM-5 diagnostic criteria. (For more on the results of the field trials, click here.) Critics contend—and Regier confirms—that the trials fail to explicitly compare the criteria suggested for the DSM-5 to that in the DSM-IV, except in the case of post-traumatic stress disorder. That is like a taste test in which the judges decide that a new diet soda is better than its non-diet predecessor because everyone approved of the flavor, even though the judges never bothered to directly compare the diet and regular versions. Although in past revisions the APA has done such a comparison, Regier says that this time doing so would double the size of the survey, making it too costly and time-consuming to conduct. “You just don’t do science that way,” Frances says. *Ferris Jabr is an Associate Editor at Scientific American Tomorrow: Edward Shorter, a historian of psychiatry at the University of Toronto, argues that the principal diagnoses of the DSM—depression, schizophrenia and bipolar disorder—are artifacts and should essentially be discarded. 
About the Author: Ingrid Wickelgren is an editor at Scientific American Mind, but this is her personal blog at which, at random intervals, she shares the latest reports, hearsay and speculation on the mind, brain and behavior. Follow on Twitter @iwickelgren.
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