Somatic Symptom Disorder could capture millions more under mental health diagnosis

May 26, 2012 by

Somatic Symptom Disorder could capture millions more under mental health diagnosis

Post #172 Shortlink: http://wp.me/pKrrB-29B

By Suzy Chapman | Dx Revision Watch

Update: My submission to the Somatic Symptom Disorder Work Group in response to the third DSM-5 draft and stakeholder review can be read here: Chapman Response to Third Draft DSM-5 SSD Proposals

May 26, 2012

While media and professional attention has been focused on the implications for introducing new disorders into the DSM and lowering diagnostic thresholds for existing categories, the Somatic Symptom Disorders (SSD) Work Group has been quietly redefining DSM’s Somatoform Disorders with radical proposals that could bring millions more patients under a mental health diagnosis.

The SSD Work Group is proposing to rename the Somatoform Disorders section of DSM-IV to “Somatic Symptom Disorders,” eliminate four existing  DSM-IV categories: somatization disorder [300.81], hypochondriasis [300.7], pain disorder*, and undifferentiated somatoform disorder [300.82] and replace them with a single new category – “Somatic Symptom Disorder.”

*In DSM-IV: Pain Disorder associated with a general medical condition (only): Psychological factors, if present, are judged to play no more than a minimal role. This is not considered a mental disorder so it is coded on Axis III with general medical conditions.See http://behavenet.com/pain-disorder for definitions and criteria for other DSM-IV presentations of Pain disorder.  For DSM-5, it appears that all presentations of Pain disorder will be subsumed under the new SSD category.

If approved, these proposals will license the application of a mental health diagnosis for all illnesses – whether “established general medical conditions or disorders” like diabetes, heart disease and cancer or conditions presenting with “somatic symptoms of unclear etiology” – if the clinician considers the patient is devoting too much time to their symptoms and that their life has become “subsumed” by health concerns and preoccupations, or their response to distressing somatic symptoms is “excessive” or “disproportionate,” or their coping strategies “maladaptive.”

Somatoform Disorders – disliked and dysfunctional

The SSD Work Group, under Chair, Joel E. Dimsdale, MD, says current terminology for the Somatoform Disorders is confusing and flawed; that no-one likes these disorders and they are rarely used in clinical psychiatric practice. Primary Care physicians don’t understand the terms and patients find them demeaning and offensive [1,2].

The group says the terms foster mind/body dualism; that the concept of “medically unexplained” is unreliable, especially in the presence of medical illness, and cites high prevalence of presentation with “medically unexplained somatic symptoms” (MUS) in general medical settings – 20% in Primary Care, 40% in Specialist Care, 33-61% in Neurology; that basing a diagnosis of psychiatric disorder on MUS alone is too sensitive.

The Work Group might have considered dispensing altogether with a clutch of disliked, dysfunctional categories. Instead, the group proposes to rebrand these disorders and assign new criteria that will capture patients with diverse illnesses, expanding application of psychiatric services, antidepressants and behavioural therapies like CBT, for the “modification of dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors.”

Focus shifts from “medically unexplained” to “excessive thoughts, behaviors and feelings”

The Work Group’s proposal is to deemphasize “medically unexplained” as the central defining feature of this disorder group.

For DSM-5, focus shifts to the patient’s cognitions – “excessive thoughts, behaviors and feelings” about the seriousness of distressing and persistent somatic (bodily) symptoms – which may or may not accompany diagnosed general medical conditions – and the extent to which “illness preoccupation” is perceived to “dominate” or “subsume” the patient’s life.

“[The SSD Work Group’s] framework will allow a diagnosis of somatic symptom disorder in addition to a general medical condition, whether the latter is a well-recognized organic disease or a functional somatic syndrome such as irritable bowel syndrome or chronic fatigue syndrome…” [3]

“…These disorders typically present first in non-psychiatric settings and somatic symptom disorders can accompany diverse general medical as well as psychiatric diagnoses. Having somatic symptoms of unclear etiology is not in itself sufficient to make this diagnosis. Some patients, for instance with irritable bowel syndrome or fibromyalgia would not necessarily qualify for a somatic symptom disorder diagnosis. Conversely, having somatic symptoms of an established disorder (e.g. diabetes) does not exclude these diagnoses if the criteria are otherwise met…” [4]

To meet requirements for Somatization Disorder (300.81) in DSM-IV, a considerably more rigorous criteria set needed to be fulfilled: a history of many medically unexplained symptoms before the age of thirty, resulting in treatment sought or psychosocial impairment. The diagnostic threshold was set high – a total of eight or more medically unexplained symptoms from four, specified symptom groups, with at least four pain and two gastrointestinal symptoms.

In DSM-5, the requirement for eight symptoms is dropped to just one.

One distressing symptom for at least six months duration and one “B type” cognition is all that is required to tick the box for a bolt-on diagnosis of a mental health disorder – cancer + SSD; angina + SSD; diabetes + SSD; IBS + SSD…

The most recent proposals for new category “J 00 Somatic Symptom Disorder.”

Note that the requirement for “at least two from the B type criteria” for the second draft has been reduced to “at least one from the B type criteria” for the third iteration of draft proposals. This lowering of the threshold is presumably in order to accommodate the merging of the previously proposed “Simple Somatic Symptom Disorder” category into the “Complex Somatic Symptom Disorder” category, a conflation now proposed to be renamed to “Somatic Symptom Disorder.” No revised “Disorder Description” and “Rationale/Validity” documents reflecting the changes made between draft two and draft three were issued for the third and final draft.

Ed: Update: Following closure of the third stakeholder review on June 15, 2012, proposals, criteria and rationales were frozen and the DSM-5 Development website was not updated to reflect any subsequent revisions. Proposals, criteria and rationales, as posted for the third draft in May 2012, were removed from the DSM-5 Development website on November 15, 2012 and placed behind a non public log in. Consequently, criteria as they had stood for “Somatic Symptom Disorder” at the point at which the third draft was issued can no longer be accessed but are set out on Slide 9 in this presentation, which note, does not include three, optional Severity Specifiers that were included with the third draft criteria. Since any changes to the drafts are embargoed in preparation for publication of DSM-5, in May 2013, I cannot confirm whether any changes have been made to the draft subsequent to June 15, 2012.

IASP and the Classification of Pain in ICD-11  Prof. Dr. Winfried Rief, University of Marburg, Germany

Slide 9

Rief Presentation ICD-11 Pain

How are highly subjective and difficult to measure constructs like “Disproportionate and persistent thoughts about the seriousness of one’s symptoms” and “Excessive time and energy devoted to these symptoms or health concerns” to be operationalized?

By what means would a practitioner determine how much of a patient’s day spent “searching the internet looking for data” (to quote an example of the SSD Work Group Chair) might be considered a reasonable response to chronic health concerns and what should be coded as “excessive preoccupation” or indicate that this patient’s life has become “subsumed” or “overwhelmed” by concerns about illness and symptoms? One hour day? Two hours? Three?

At the APA’s Annual Conference earlier this month, SSD Work Group Chair, Joel E. Dimsdale, presented an update on his group’s deliberations. During the Q & A session, an academic professional in the field expressed concern that practitioners who are not psychiatric professionals or clinicians might have some difficulty interpreting the wording of the B type criteria to differentiate between negative and positive coping strategies.

Dr Dimsdale was asked to expand on how the B type criteria would be defined and by what means patients with chronic medical conditions who devote time and energy to health care strategies to try to improve their symptoms and level of functioning would be evaluated in the field by the very wide range of DSM users; how would these patients be differentiated from patients considered to be spending “excessive time and energy devoted to symptoms or health concerns” or perceived as having become “absorbed” by their illness?

I am not persuaded by Dr Dimsdale’s reassurances that his Work Group will try to make this “crystal clear” in the five to six pages of manual text in the process of being drafted for this disorder chapter. Nor am I reassured that these B (1), (2) and (3) criteria can be safely applied outside the optimal conditions of field trials, in settings where practitioners may not necessarily have the time for, nor instruction in administration of diagnostic assessment tools, and where decisions to code or not to code may hang on arbitrary and subjective perceptions of DSM end-users lacking clinical training in the use of the manual text and application of criteria.

Implications for a diagnosis of SSD for all patient populations

Incautious, inept application of criteria resulting in a “bolt-on” psychiatric diagnosis of a “Somatic Symptom Disorder” could have far-reaching implications for all patient populations:

• Application of highly subjective and difficult to measure criteria could potentially result in misdiagnosis with a mental health disorder, misapplication of an additional diagnosis of a mental health disorder or missed diagnoses through dismissal and failure to investigate new or worsening somatic symptoms.

• Patients with cancer and life threatening diseases may be reluctant to report new symptoms that might be early indicators of local recurrence, metastasis or secondary disease, for fear of attracting a diagnosis of “SSD” or of being labelled as “catastrophisers.”

• Application of an additional diagnosis of Somatic Symptom Disorder may have implications for the types of medical investigations, tests and treatments that clinicians are prepared to consider and which insurers prepared to fund.

• Application of an additional diagnosis of Somatic Symptom Disorder may impact payment of employment, medical and disability insurance and the length of time for which insurers are prepared to pay out. It may negatively influence the perceptions of agencies involved with the assessment and provision of social care, disability adaptations, education and workplace accommodations.

• Patients prescribed psychotropic drugs for perceived unreasonable levels of “illness worry” or “excessive preoccupation with symptoms” may be placed at risk of iatrogenic disease or subjected to inappropriate behavioural therapies.

• For multi-system diseases like Multiple Sclerosis, Behçet’s syndrome or Systemic lupus it can take several years before a diagnosis is arrived at. In the meantime, patients with chronic, multiple somatic symptoms who are still waiting for a diagnosis would be vulnerable.

• The burden of the DSM-5 changes will fall particularly heavily upon women who are more likely to be casually dismissed when presenting with physical symptoms and more likely to receive inappropriate antidepressants and anti-anxiety medications for them.

• Proposals allow for the application of a diagnosis of Somatic Symptom Disorder where a parent is considered excessively concerned with a child’s symptoms [3]. Families caring for children with any chronic illness may be placed at increased risk of wrongful accusation of “over-involvement” with a child’s symptomatology.

Where a parent is perceived as encouraging maintenance of “sick role behaviour” in a child, this may provoke social services investigation or court intervention for removal of a sick child out of the home environment and into foster care or for enforced in-patient “rehabilitation.” This is already happening in families with a child or young person with chronic illness, notably with Chronic fatigue syndrome or ME. It may happen more frequently with a diagnosis of a chronic childhood illness + SSD.

Dustbin diagnosis?

Although the Work Group is not proposing to classify Chronic fatigue syndrome, IBS and fibromyalgia, per se, within the Somatic Symptom Disorders, patients with CFS – “almost a poster child for medically unexplained symptoms as a diagnosis,” according to Dr Dimsdale’s presentation – or with fibromyalgia, irritable bowel syndrome, chronic Lyme disease, Gulf War illness, chemical injury and chemical sensitivity may be particularly vulnerable to misapplication or misdiagnosis with a mental health disorder under these SSD criteria.

There is considerable concern that this new Somatic Symptom Disorder category will provide a “dustbin diagnosis” in which to shovel the so-called “functional somatic syndromes.”

15% of “diagnosed illness” and 26% of “functional somatic” captured by SSD criteria

For testing reliability of CSSD criteria, three groups were studied for the field trials:

488 healthy patients; a “diagnosed illness” group of 205 patients with cancer and malignancy (some in this group were said to have severe coronary disease) and a “functional somatic” group comprising 94 people with irritable bowel and “chronic widespread pain” (a term used synonymously with fibromyalgia).

Patients in the study were required to meet one to three cognitions: Do you often worry about the possibility that you have a serious illness? Do you have the feeling that people are not taking your illness seriously enough? Is it hard for you to forget about yourself and think about all sorts of other things?

Dr Dimsdale reports that if the response was “Yes – a lot.” then [CSSD] was coded.

15% of the cancer and malignancy group met SSD criteria when “one of the B type criteria” was required; if the threshold was increased to “two B type criteria” about 10% met criteria for dual-diagnosis of diagnosed illness + Somatic Symptom Disorder.

For the 94 irritable bowel and “chronic widespread pain” study group, about 26% were coded when one cognition was required; 13% coded with two cognitions required.

Has the SSD Work Group produced projections for prevalence estimates and potential increase in mental health diagnoses across the entire disease landscape?

Did the Work Group seek opinion on the medico-legal implications of missed diagnoses?

Has the group factored for the clinical and economic burden of providing CBT for modifying perceived “dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors” in patients for whom an additional diagnosis of Somatic Symptom Disorder has been coded?

Where’s the science?

Dr Dimsdale admits his committee has struggled from the outset with these B type criteria but feels its proposals are “a step in the right direction.”

The group reports that preliminary analysis of field trial results shows “good reliability between clinicians and good agreement between clinician rated and patient rated severity.” In the trials, CSSD achieved Kappa values of .60 (.41-.78 Confidence Interval).

Kappa reliability reflects agreement in rating by two different clinicians corrected for chance agreement – it does not mean that what they have agreed upon are valid constructs.

Radical change to the status quo needs grounding in scientifically validated constructs and a body of rigorous studies not on pet theories and papers (in some cases unpublished papers) generated by Dr Dimsdale’s work group colleagues.

Where is the substantial body of independent research evidence to support the group’s proposals?

“...To receive a diagnosis of complex somatic symptom disorder, patients must complain of at least one somatic symptom that is distressing and/or disruptive of their daily lives. Also, patients must have at least two [Ed: now reduced to at least one since evaluation of the CSSD field trials] of the following emotional/cognitive/behavioral disturbances: high levels of health anxiety, disproportionate and persistent concerns about the medical seriousness of the symptom(s), and an excessive amount of time and energy devoted to the symptoms and health concerns. Finally, the symptoms and related concerns must have lasted for at least six months.”

“Future research will examine the epidemiology, clinical characteristics, or treatment of complex somatic symptom disorder as there is no published research on this diagnostic category.”

“…Just as for complex somatic symptom disorder, there is no published research on the epidemiology, clinical characteristics, or treatment of simple somatic symptom disorder.”

Source: Woolfolk RL, Allen LA. Cognitive Behavioral Therapy for Somatoform Disorders. Standard and Innovative Strategies in Cognitive Behavior Therapy.

Where are the professionals?

During the second public review, the Somatic Symptom Disorders proposals attracted more responses than almost any other category. The SSD Work Group is aware that patients, caregivers and patient advocacy organizations have considerable concerns. But are medical and allied health professionals scrutinizing these proposals?

This is the last opportunity to submit feedback. Psychiatric and non psychiatric clinicians, primary care practitioners and specialists, allied health professionals, psychologists, counselors, social workers, lawyers, patient advocacy organizations – please look very hard at these proposals, consider their safety and the implications for an additional diagnosis of an SSD for all patient illness groups and weigh in with your comments by June 15.

Criteria and rationales for the third iteration of proposals for the DSM-5 Somatic Symptom Disorders categories can be found here on the DSM-5 Development site. [Update: Proposals were removed from the DSM-5 Development website on November 15, 2012.]

References

1 Levenson JL. The Somatoform Disorders: 6 Characters in Search of an Author. Psychiatr Clin North Am. 2011 Sep;34(3):515-24.

2 Dimsdale JE. Medically Unexplained Symptoms: A Treacherous Foundation for Somatoform Disorders? Psychiatr Clin North Am. 2011 Sep;34(3):511-3.

3 Dimsdale J, Creed F. DSM-V Workgroup on Somatic Symptom Disorders: the proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV – a preliminary report. J Psychosom Res 2009;66:473–6.

4 DSM-5 Somatic Symptom Disorders Work Group Disorder Descriptions and Justification of Criteria-Somatic Symptoms documents, published May 4, 2011 for the second DSM-5 stakeholder review.

(Caveat: for background to the SSD Work Group’s rationales only; proposals and criteria as set out in these documents have not been revised to reflect changes to revisions or reissued for the third review.)

    Disorder Descriptions   May 4, 2011

    Rationale/Validity Document   May 4, 2011

© Copyright 2015 Suzy Chapman

Filed under Criticism of DSM-V, DSM-5, DSM revision process, DSM-5, DSM-5 draft proposals, DSM-5 field trials, DSM-5 in the media, DSM-5 third draft, Functional Somatic Syndrome (FSS), Somatic Symptom Disorder, Somatoform Disorders Tagged with , , , , , , , , ,

DSM-5 in New Scientist: Psychiatry’s new diagnostic bible is creating headaches for doctors and patients alike

May 18, 2012 by

DSM-5 in New Scientist: “Psychiatry’s new diagnostic bible is creating headaches for doctors and patients alike”

Post #171 Shortlink: http://wp.me/pKrrB-293

A reminder that this third and final stakeholder review and comment period is scheduled to close on June 15.

On May 17, APA added the following statement to the home page of the DSM-5 Development site.

APA Position Statement on DSM-5 Draft Diagnostic Criteria

The official position of the APA on draft DSM-5 diagnostic criteria is that they are not to be used for clinical or billing purposes under any circumstances. They are published on the http://www.dsm5.org Web site to obtain feedback on these preliminary DSM-5 Task Force proposals from mental health professionals, patients, and the general public. They have not received official reviews or approval by the APA Board of Trustees and will not be available for clinical use or billing purposes until May 2013.

Two articles in this week’s online and print editions of New Scientist.

The first report, by Peter Aldhous, quotes Allen Frances, MD, who had chaired the development of the DSM-IV; APA research director and DSM-5 Task Force Vice Chair, Darrel Regier, and Dr Dayle Jones who is tracking DSM-5 for the American Counseling Association, on DSM-5 field trial kappa results and the relegation of Attenuated psychosis syndrome and Mixed anxiety/depression to the DSM-5 appendix.

This article is behind a paywall or a subscription to the print edition.

New Scientist 19 May 2012

Page 6 print edition

THIS WEEK/MENTAL HEALTH

Psychiatry’s new diagnostic bible is creating headaches for doctors and patients alike

Online title Trials highlight worrying flaws in psychiatry ‘bible’

Peter Aldhous

Diagnosis: uncertain

HOW reliable is reliable enough?

The second article, “OPINION ‘Label jars, not people”, by James Davies, is accessible on the New Scientist website without payment or print edition subscription.

New Scientist 19 May 2012

Page 7 print edition

OPINION | James Davies

James Davies is a senior lecturer in social anthropology and psychotherapy at the University of Roehampton, London

‘Label jars, not people’

“LABEL jars, not people” and “stop medicalising the normal symptoms of life” read placards, as hundreds of protesters – including former patients, academics and doctors – gathered to lobby the American Psychiatric Association’s (APA) annual meeting.

The demonstration aimed to highlight the harm the protesters believe psychiatry is perpetrating in the name of healing. One concern is that while psychiatric medications are more widely prescribed than almost any drugs in history, they often don’t work well and have debilitating side effects. Psychiatry also professes to respect human rights, while regularly treating people against their will. Finally, psychiatry keeps expanding its list of disorders without solid scientific justification…

Read full article

Filed under Allen Frances, American Psychiatric Association (APA), Darrel Regier, DSM-5 consultation, DSM-5 draft proposals, DSM-5 field trials, DSM-5 in the media, DSM-5 third draft, Kappa, New Scientist Tagged with , , , , , , , , ,

Two proposed changes dropped from DSM-5: Media round-up

May 10, 2012 by

Two proposed changes dropped from DSM-5: Media round-up

Post #169 Shortlink: http://wp.me/pKrrB-28a

Pharma Blog

Should A Federal Agency Oversee The DSM?

Ed Silverman | May 15, 2012

…Frances proposes that a federal agency ought to assume the job of developing the DSM, although he believes a new organization would be required, one that could be housed in the US Department of Health and Human Services, the Institute of Medicine or the World Health Organization. An equivalent of the FDA is needed to “mind the store,” as he puts it.

This may raise a different set of objections, of course. To what extent, for instance, should a federal agency delve deeply into determining diagnoses and definitions? On the other hand, perhaps this would remove the concerns over self-interest and conflict that have tainted the process. What do you think?

Should a Federal Agency Run The DSM?

Psych Central

An Epidemic of Mental Disorders?

John M. Grohol, PsyD, Founder & Editor-in-Chief | May 15, 2012

Psychiatric Times

COMMENTARY

Is There Really an “Epidemic” of Psychiatric Illness in the US?

Ronald W. Pies, MD | May 1, 2012

Epidemic: (from epidēmos, prevalent : epi-, epi- + dēmos, people) “…an epidemic refers to an excessive occurrence of a disease.”–from Friis & Sellers, Epidemiology for Public Health Practice, 4th ed, 2010

If claims in the non-professional media can be believed, there is a “raging epidemic of mental illness” in the US¹, if not world-wide—and, in one version of this narrative, psychiatric treatment itself is identified as the culprit. There are several formulations of the “epidemic narrative,” depending on which of psychiatry’s critics is writing. In the most radical version, it is psychiatric medication that is fueling the supposed burgeoning of mental illness, particularly depression and schizophrenia.² More subtle variants suggest that there is a “false epidemic” of some psychiatric disorders, driven by dramatically rising rates of “false positive” diagnoses.³…

Time Healthland

Mental Health

DSM 5 Could Mean 40% of College Students Are Alcoholics

Maia Szalavitz | May 14, 2012

Most college binge drinkers and drug users don’t develop lifelong problems. But new mental-health guidelines will label too many of them addicts and alcoholics…

Side Effects at Psychology Today

DSM-5 Is Diagnosed, with a Stinging Rebuke to the APA
The regrettable history of the DSM

Christopher Lane, Ph.D. | May 14, 2013

…Among the fiercest critics quoted is Mark Rapley, a clinical psychologist at the University of East London, who puts it this way: “The APA insists that psychiatry is a science. [But] real sciences do not decide on the existence and nature of the phenomena they are dealing with via a show of hands with a vested interest and pharmaceutical industry sponsorship.” Despite commending the DSM-5 authors for “reconsidering some of their most unfortunate mistakes,” clinical psychologist Peter Kinderman of the University of Liverpool adds that the manual remains, at bottom, a bad and faulty system. “The very minor revisions recently announced do not constitute the wholesale revision that is called for,” he is quoted as saying. “It would be very unfortunate if these minor changes were to be used to suggest that the task force has listened in any meaningful way to critics….”

The New American

Critics Blast Big Psychiatry for Invented and Redefined Mental Illnesses

Alex Newman | May 13, 2012

Allen J Frances lecture

Published on 11 May 2012 by tvochannel

Psychiatrist and author, Allen J. Frances, believes that mental illnesses are being over-diagnosed. In his lecture, Diagnostic Inflation: Does Everyone Have a Mental Illness?, Dr. Frances outlines why he thinks the DSM-V will lead to millions of people being mislabeled with mental disorders. His lecture was part of Mental Health Matters, an initiative of TVO in association with the Centre for Addiction and Mental Health.

Podcast http://bit.ly/KhLuhd

57:36 mins | 19 MB

As part of Mental Health Matters Week, Big Ideas presents a lecture by Allen J Frances, MD, who had chaired the DSM-IV Task Force.

Website http://a2zn.com/?p=3507

News wire

May 6, 2012 University of Toronto

Produced in collaboration with the Center for Addiction and Mental Health

Allen J Frances lecture

Diagnostic inflation. Does everyone have a mental illness?

Big Ideas – May 12 and 13 at 5 pm ET

TVO’s lecture series will present special guest speaker Dr. Allen J. Frances, who will outline why he believes that mental illnesses are being over-diagnosed these days and why he thinks the fifth and latest version of the psychiatrist’s bible, Diagnostic and Statistical Manual of Mental Disorders will lead to millions of people being mislabeled with mental disorders.

The lecture will be recorded May 6 at University of Toronto’s Hart House.

1 Boring Old Man

the dreams of our fathers I…

1 Boring Old Man |  May 12, 2012

University Diaries

“Diagnostic Exuberance”…

Margaret Soltan | May 13, 2012

BMJ News

More psychiatrists attack plans for DSM-5

BMJ 2012; 344 doi: 10.1136/bmj.e3357 (Published 11 May 2012)

Geoff Watts

The authors of the 5th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), due to be published in May 2013, have responded to previous criticisms of their text by announcing a further series of changes.1

But far from mollifying their critics, these concessions have served to ignite a further and still more vituperative barrage of dissent.

The list of topics under reconsideration or already subject to change can be found on the DSM-5 website.2 It includes the proposed “attenuated psychosis syndrome,” which is slated for further study, and also major depressive disorder. Here the authors have added a footnote “to …

Access to the full text of this article requires a subscription or payment

Scientific American Blogs

Why Are There No Biological Tests in Psychiatry?

By Ingrid Wickelgren | May 11, 2012 | 2

Part 5 of a 5-part series Allen Frances

New York Times

Op-Ed Contributor

Diagnosing the D.S.M.

Allen Frances | May 11, 2012

“…All mental-health disciplines need representation — not just psychiatrists but also psychologists, counselors, social workers and nurses. The broader consequences of changes should be vetted by epidemiologists, health economists and public-policy and forensic experts. Primary care doctors prescribe the majority of psychotropic medication, often carelessly, and need to contribute to the diagnostic system if they are to use it correctly. Consumers should play an important role in the review process, and field testing should occur in real life settings, not just academic centers.

Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists. They will always be an essential part of the mix but should no longer be permitted to call all the shots…”

MedPage Today

DSM-5: What’s In, What’s Out

John Gever, Senior Editor, MedPage Today |  May 10, 2012

   …The final drafts are to be completed by August, then they must be approved by a scientific review committee and the task force leadership, and finally by the APA’s governing bodies.

Kupfer said the final version has to be completed by December, when it’s set to go to the printer. Its formal release is planned for the APA’s annual meeting next May in San Francisco.

Here’s a brief overview of the changes you can expect…

WHAT’S OUT
WHAT’S IN (or STILL IN)
WHAT DIDN’T MAKE IT
WHAT TO LOOK FORWARD TO

Reuters 1

Two proposed changes dropped from psychiatric guide

Julie Steenhuysen | Reuters CHICAGO | May 9, 2012

CHICAGO (Reuters) – Two proposed psychiatric diagnoses failed to make the last round of cuts in the laborious process of revising the Diagnostic and Statistical Manual of Mental Disorders — an exhaustive catalog of symptoms used by doctors to diagnose psychiatric illness.

Gone from the latest revision are “attenuated psychosis syndrome,” intended to help identify individuals at risk of full-blown psychosis, and “mixed anxiety depressive disorder”, a blend of anxiety and depression symptoms. Both performed badly on field tests and in public comments gathered by the group in its march toward the May 2013 publication deadline.

Both have been tucked into Section III of the manual — the place reserved for ideas that do not yet have enough evidence to make the cut as a full-blown diagnosis.

What has survived, despite fierce public outcry, is a change in the diagnosis of autism, which eliminates the milder diagnosis of Asperger syndrome in favor of the umbrella diagnosis of autism spectrum disorder.

But that, too, could still be altered before the final manual is published, the group says. The APA opened the final comment period for its fifth diagnostic manual known as DSM-V on May 2, and it will accumulate comments through June 15.

Dr. David Kupfer, who chairs the DSM-5 Task Force, said in a statement that the changes reflect the latest research and input from the public.

Dr. Wayne Goodman, professor and chairman of the department of psychiatry at Mount Sinai Medical Center in New York, said he’s glad the task force is responding to feedback from professionals and the public.

“I think they are trying to listen,” he said.

Goodman agrees with the decisions to drop both of the two disorders in the latest revision.

With the “mixed anxiety and depressive disorder,” he said there was a risk that it would capture a number of people who did not qualify under a diagnosis of depression or anxiety alone.

“It could lead to overdiagnosis,” Goodman said.

He said the “attenuated psychosis syndrome” diagnosis would have been useful for research purposes to help identify those at risk of psychosis, but there was a concern that it might label people who were just a bit different as mentally ill.

“The predictive value is not clear yet,” he said. “I think it’s reasonable not to codify it until we have better definition of its predictive value.”

Goodman, who worked on DSM-4, the last revision of the manual published in 1994, and is working on the Obsessive Compulsive Disorder section of the current revision of DSM-5, said the strength of the process is that it can offer a reliable way for psychiatrists across the country to identify patients with the same sorts of disorders.

The weakness, he said, is that it largely lacks biological evidence — blood tests, imaging tests and the like — that can validate these diagnoses.

“DSM-5 is a refinement of our diagnostic system, but it doesn’t add to our ability to understand the underlying illness,” he said.

Dr. Emil Coccaro, chairman of the Department of Psychiatry and Behavioral Neuroscience at the University of Chicago Medicine, said typically changes in the DSM occur because of new data.

Coccaro, who is contributing to the new section in the DSM-5 on Intermittent Explosive Disorder, said there is no question that many people aren’t convinced that some of the diagnoses need to be changed, or that there need to be new ones added.

“This also happened the last time when they did DSM-4,” he said, but that was nearly 20 years ago.

“You can keep waiting but at certain point you have to fish or cut bait and actually come out with a new edition. That is what is happening now,” he said.

Comments to the manual can be submitted at www.DSM5.org

(Reporting By Julie Steenhuysen)

Reuters 2

Experts unconvinced by changes to psychiatric guide

Kate Kelland | Reuters LONDON | May 10, 2012

(Reuters) – Many psychiatrists believe a new edition of a manual designed to help diagnose mental illness should be shelved for at least a year for further revisions, despite some modifications which eliminated two controversial diagnoses.

The new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) is due out this month, the first full revision since 1994 of the renowned handbook, which is used worldwide and determines how to interpret symptoms in order to diagnose mental illnesses.

But more than 13,000 health professionals from around the world have already signed an open letter petition (at dsm5-reform.com) calling for DSM 5 to be halted and re-thought.

“Fundamentally, it remains a bad system,” said Peter Kinderman, a professor of clinical psychology at Britain’s Liverpool University.

“The very minor revisions…do not constitute the wholesale revision that is called for,” he said in an emailed comment.

The American Psychiatric Association (APA), which produces the DSM, said on Wednesday it had decided to drop two proposed diagnoses, for “attenuated psychosis syndrome” and “mixed anxiety depressive disorder”.

The former, intended to help identify people at risk of full-blown psychosis, and the latter, which suggested a blend of anxiety and depression, had been criticized as too ill-defined.

With these and other new diagnoses such as “oppositional defiant disorder” and “apathy syndrome”, experts said the draft DSM 5 could define as mentally ill millions of healthy people – ranging from shy or defiant children to grieving relatives, to people with harmless fetishes.

“SIMPLY NOT USABLE”

Robin Murray, a professor of psychiatric research at the Institute of Psychiatry at Kings College London, said it was a great relief to see the changes in the draft, particularly to the attenuated psychosis diagnosis.

“It would have done a lot of harm by diverting doctors into thinking about imagined risk of psychosis (and) it would have led to unnecessary fears among patients that they were about to go mad,” he said in a statement.

But Allen Frances, emeritus professor at Duke University in the United States, said: “This is only a first small step toward desperately needed DSM 5 reform. Numerous dangerous suggestions remain.”

Frances, who chaired a committee overseeing the DSM 4, added that the DSM 5 “is simply not usable” and should be delayed for a year “to allow for independent review, to clean up its obscure writing, and for retesting”.

Diagnosis is always controversial in psychiatry, since it defines how patients will be treated based on a cluster of symptoms, many of which occur in several different types of mental illness.

Some argue that the whole approach needs to be changed to pay more attention to individual circumstances rather than slotting them into predefined categories.

“(The DSM) is wrong in principle, based as it is on redefining a whole range of understandable reactions to life circumstances as ‘illnesses’, which then become a target for toxic medications heavily promoted by the pharmaceutical industry,” said Lucy Johnstone, a consultant clinical psychologist for the Cwm Taf Health Board in Wales.

“The DSM project cannot be justified, in principle or in practice. It must be abandoned so that we can find more humane and effective ways of responding to mental distress.”

Others, however, are pushing more for the manual to be reviewed more thoroughly to allow for more accurate diagnosis and, in theory, more appropriate treatment.

One of the proposed changes that has survived in the draft DSM 5 – despite fierce public outcry – is in autism. The new edition eliminates the milder diagnosis of Asperger syndrome in favor of the umbrella diagnosis of autism spectrum disorder.

(Editing by Myra MacDonald)

New York Times

Psychiatry Manual Drafters Back Down on Diagnoses

Benedict Carey | 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.

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 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 mainly to field trials — real-world studies testing whether newly proposed diagnoses are reliable from one psychiatrist to the next — and also public commentary. “Our intent for disorders that require more evidence is that they be studied further, and that people work with the criteria” and refine them, Dr. Kupfer said…

CBS News

Panel suggests DSM-5 psychiatry manual drops two disorders, keeps new autism definition

Michelle Castillo | May 10, 2012

(CBS News) – A panel of doctors reviewing the much-debated Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) have recommended to drop two controversial diagnoses.

The panel announced that attenuated psychosis syndrome — which identifies people at risk of developing psychosis — and mixed anxiety depressive disorder — a diagnosis which combines both anxiety and depression — should not be included in the manual’s upcoming version, the New York Times reported.

Proposed changes to autism definition may mean new diagnoses for people with Asperger’s

However, a controversial definition for autism, which will delete diagnoses for Asperger’s syndrome and pervasive developmental disorder and combine severe cases into the broader definition of autism, will remain…

MedPage Today

Autism Criteria Critics Blasted by DSM-5 Leader

John Gever, Senior Editor | May 08, 2012

PHILADELPHIA — The head of the American Psychiatric Association committee rewriting the diagnostic criteria for autism spectrum disorders took on the panel’s critics here, accusing them of bad science.

Susan Swedo, MD, of the National Institute of Mental Health, said a review released earlier this year by Yale University researchers was seriously flawed. That review triggered a wave of headlines indicating that large numbers of autism spectrum patients could lose their diagnoses and hence access to services…

Nature

Psychosis risk syndrome excluded from DSM-5

Benefits of catching psychosis early are deemed to come at too high a price.

Amy Max | May 9, 2012

A controversial category of mental illness will not be included in the revised fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Psychiatric Association (APA) has said. Attenuated psychosis syndrome, also known as psychosis risk syndrome, had been intended mainly for young adults who have heard whispers in their heads, viewed objects as threatening or suffered other subtly psychotic symptoms…

Scientific American Blogs

Trouble at the Heart of Psychiatry’s Revised Rule Book

Ingrid Wickelgren | May 9, 2012

Part 3 in a series

Huffington Post | Allen Frances Blog

Psychiatric Mislabeling Is Bad for Your Mental Health

Allen Frances, MD | May 9, 2012

Filed under Allen Frances, American Psychiatric Association (APA), David Kupfer, DSM-5 consultation, DSM-5 draft proposals, DSM-5 field trials, DSM-5 in the media, DSM-5 Petitions, DSM-5 third draft Tagged with , , , , , , , , ,

DSM-5 Somatic Symptom Disorders: Differences between second and third draft for CSSD

May 9, 2012 by

DSM-5 Somatic Symptom Disorders: Differences between second and third draft for CSSD

Post #168 Shortlink: http://wp.me/pKrrB-27y

A reminder that the third and final DSM-5 comment period closes on June 15 and that I am collating submissions on this site.

Comments are open to professional and lay stakeholders. Please alert clinicians, researchers, allied health professionals, social workers, lawyers, educationalists, therapists, patient advocacy groups to these proposals.

Full proposals, criteria and rationales for the Somatic Symptom Disorders are set out in this post:

DSM-5 proposals for Somatoform Disorders revised on April 27, 2012

According to DSM-5 Task Force Chair, David Kupfer, MD, “After the comment period closes, visitors will no longer be able to submit feedback through the site, and the site will not reflect any further revisions to the draft manual in anticipation of its publication in May 2013. However, the site will remain live and viewable.”

 

Somatic Symptom Disorders Work Group proposals:

Two PDF Disorder Descriptions and Rationale/Validity Propositions PDF documents had accompanied the first and second drafts. There are no revised PDFs reflecting the most recent proposals available on the DSM-5 Development website and the documents published with the second draft have been removed.

I have asked the APA’s Media and Communications Office to clarify whether the Somatic Symptom Disorder Work Group intends to publish revised Disorder Descriptions or Rationale/Validity Propositions documents during the life of the stakeholder review period or whether these documents are being dispensed with for this third draft.

Should updated documents be added to the site during the comment period I will post links.

 

Notes on differences between the second and third draft proposals for CSSD

As with the first and second drafts, the intention remains to rename the Somatoform Disorders section to Somatic Symptom Disorders.

The proposal continues to combine the existing DSM-IV categories:

Somatization Disorder
Hypochondriasis
Undifferentiated Somatoform Disorder
Pain Disorder

into a single new category, Somatic Symptom Disorder.

For the second draft, the work group had suggested two separate diagnoses, Complex Somatic Symptom Disorder CSSD) and Simple Somatic Symptom Disorder (SSSD).

Following evaluation of the results of the DSM-5 field trials, the Somatic Symptom Disorders Work Group has decided that Simple Somatic Symptom Disorder  is “a less severe variant of CSSD.”

The Work Group now proposes merging CSSD and SSSD into a single category called Somatic Symptom Disorder (SSD) and is suggesting dropping the word “Complex” from the category term.

The latest proposed category names for the revision of the DSM-IV’s Somatoform Disorders now look like this:

Somatic Symptom Disorders

J 00 Somatic Symptom Disorder – with the option for specifying:

Mild Somatic Symptom Disorder
Moderate Somatic Symptom Disorder
Severe Somatic Symptom Disorder

J 01 Illness Anxiety Disorder |
J 02 Conversion Disorder (Functional Neurological Symptom Disorder) |
J 03 Psychological Factors Affecting Medical Condition |
J 04 Factitious Disorder |
J 05 Somatic Symptom Disorder Not Elsewhere Classified |

Revised Criteria, Rationale and Severity texts for the above can be found at the links above or on this webpage:

http://www.dsm5.org/ProposedRevision/Pages/SomaticSymptomDisorders.aspx

These are the criteria for J00 Somatic Symptom Disorder

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=368

J 00 Somatic Symptom Disorder

Updated April-27-2012

Proposed Revision

Somatic Symptom Disorder

Note that the criteria for CSSD in the previous draft, released in May 2011, had read:

“B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least two of the following must be present.”

But for the third draft, this has been reduced to

“B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least one of the following must be present.”

This is presumably to accommodate Simple Somatic Symptom Disorder within what had been the criteria for CSSD.

(Last year, for the second draft, the criteria for CSSD had required two from (1), (2) and (3) and a symptom duration of greater than 6 months, whereas the criteria for SSSD had required only one from (1), (2) and (3) and a symptom duration of greater than one month.)

 

Note also that the option for three Severity Specifiers for J00 Somatic Symptom Disorder category: Mild, Moderate, Severe, might potentially be intended to correspond to three newly proposed categories in the ICD-11 Chapter 5: Somatoform Disorders section.

In the ICD-11 Alpha drafting platform (which is a work in progress and comes with caveats), the Somatoform Disorders categories are currently proposed to be renamed to Bodily Distress Disorders. There are three new categories listed:

6R0 Mild bodily distress disorder
6R1 Moderate bodily distress disorder
6R2 Severe bodily distress disorder

These three new category suggestions have no definitions or descriptive parameters visible in the ICD-11 Alpha draft so it isn’t possible to determine at this stage what disorders these newly suggested terms might be intended to capture; nor how they would relate to the existing somatoform disorders categories that still remain listed beneath them in this section of the Alpha draft.

For comparison, this is how the corresponding section of ICD-11 categories currently displays:

ICD-11 Alpha draft:

BODILY DISTRESS DISORDERS [Formerly Somatoform Disorders]

6R0 Mild bodily distress disorder
6R1 Moderate bodily distress disorder
6R2 Severe bodily distress disorder
6R3 Somatization disorder
6R4 Undifferentiated somatoform disorder
6R5 Somatoform autonomic dysfunction
6R6 Persistent somatoform pain disorder
     6R6.1 Persistent somatoform pain disorder
     6R6.2 Chronic pain disorder with somatic and psychological factors [not in ICD-10]
6R7 Other somatoform disorders
6R8 Somatoform disorder, unspecified

Hypochondriacal disorder [ICD-10: F45.2] is currently listed in ICD-11 Chapter 5 as Illness Anxiety Disorder under 6L5 ANXIETY AND FEAR-RELATED DISORDERS > 6L5.6 Illness Anxiety Disorder.

Dissociative (Conversion disorders) [ICD-10: F44] is currently listed in ICD-11 Chapter 5 under Neurotic, stress-related and somatoform disorders > 7A5 Dissociative [conversion] disorders.

There had been discussions by the SSD and Dissociative Disorders work groups for potentially locating Conversion Disorder under the DSM-5 Dissociative Disorders section, for congruency with its location within ICD-10.

For the third draft, it appears that the groups with oversight of the revision of conversion disorder have decided that this category should be renamed to Conversion Disorder (Functional Neurological Symptom Disorder) and classified as a Somatic Symptom Disorder.

In a future post, for ease of comparison, I will post a table comparing DSM-5 third draft proposals with current listings for ICD-11.

 

Links:

1] Somatic Symptom Disorders Third draft proposals:
http://www.dsm5.org/ProposedRevision/Pages/SomaticSymptomDisorders.aspx

2] Bodily Distress Disorders” to replace “Somatoform Disorders” for ICD-11?
http://wp.me/pKrrB-1Vx

3] DSM-5 proposals for Somatoform Disorders revised on April 27, 2012
http://wp.me/pKrrB-24D

4] Submissions to SSD Work Group May 2011 are archived here:
http://wp.me/PKrrB-19a

5] Submissions to SSD Work Group May 2012 are being collated here:
http://wp.me/PKrrB-1Ol

Filed under Bodily Distress Disorders, DSM revision process, DSM-5 consultation, DSM-5 draft proposals, DSM-5 field trials, DSM-5 third draft, ICD-11 Alpha Draft, Somatic Symptom Disorder, Somatoform Disorders Tagged with , , , , , , , , ,

More Kappa data from DSM-5 field trials

May 9, 2012 by

More Kappa data from DSM-5 field trials

Post #167 Shortlink: http://wp.me/pKrrB-27D

Further data from the DSM-5 field trials results have been released in a report by Deborah Brauser for Medscape Medical News.

You can read Ms Brauser’s report from the American Psychiatric Association’s annual conference here, though you may need to register for the site:

Medscape Medical News > Psychiatry

DSM-5 Field Trials Generate Mixed Results

Deborah Brauser | May 8, 2012

…Members of the task force said they hope to publish the full results “within a month.” However, the third and final public comment period for the manual opened last week and ends on June 15. Although the entire period is 6 weeks long, the public may only have 2 weeks to comment after the publication of the field trials’ findings.

…“No previous field trial had such a sophisticated design. And it has resulted in more statistically significant data for specific disorders,” said Dr. Regier.

The current DSM-5 field trials, as well as field trials for past manuals, use Kappa score as a statistical measure of criteria reliability. A Kappa score of 1.0 was considered perfect, a score of greater than .8 was considered almost perfect, a score of .6 to .8 was considered good to very good, a score of .4 to .6 was considered moderate, a score of .2 to .4 was considered fair and could be accepted, and a score of less than .2 was considered poor.

 At adult sites, schizophrenia was shown to have a pooled Kappa score of .46. However, that is down from the .76 and .81 Kappa scores found in the DSM-IV and DSM-III, respectively, and it is less than the .79 score found in the International Classification of Diseases, Tenth Revision (ICD-10).

“It’s important to realize in some ways that the Kappa in the current field trial was from a totally different design…,” said Dr. Regier

Full report

This table has some of the results:


Reconstructed from data published by A Frances, DSM 5 in Distress, Psychology Today, 05.06.12

 

1 Boring Old Man has updated an earlier table here on his blog which incorporates additional data from the Medscape report: 

updated table
1 Boring Old Man | May 9, 2012

There are further, detailed commentaries from 1 boring old man on the DSM-5 field trial results and Kappa values here:

major depressive disorder κ=0.30?…     May 6, 2012

a fork in the road…     May 7, 2012

Village Consumed by Deadly Storm…     May 8, 2012

box scores and kappa…     May 8, 2012

Included in Ms Brauser’s report are data for “Complex somatic disorder”:

The field trials for the new proposed category Complex Somatic Symptom Disorder (CSSD) were held at Mayo. According to one of several tables within Ms Brauser’s report, the following data have been released for “Complex somatic disorder” [sic]:

Extract from DSM-5 Field Trials Generate Mixed Results, Deborah Brauser,  May 8, 2012

Disorder DSM-5 (95% CI) DSM-IV ICD-10 DSM-III
Major neurocognitive disorder .78 (.68 – .87) — .66 .91
ASD .69 (.58 – .80) .59 – .85 .77 -.01
PTSD .67 (.59 – .74) .59 .76 .55*
Child ADHD .61 (.51 – .72) .59 .85 .50
Complex somatic disorder .60 (.41 – .78) — .45 .42

CI, confidence interval; ASD, autism spectrum disorder; PTSD, posttraumatic stress disorder; ADHD, attention-deficit/hyperactivity disorder

*From the DSM-III-R.

CSSD is a new category for DSM-5 which redefines and replaces some, but not all of the existing DSM-IVSomatoform Disorders categories under a new rubric with a new definition and criteria.

It’s a mashup of the existing categories:

Somatization Disorder
Hypochondriasis
Undifferentiated Somatoform Disorder
Pain Disorder

Following evaluation of the field trials, this new category, Complex Somatic Symptom Disorder is now proposed to drop the “Complex” descriptor, be named Somatic Symptom Disorder and absorb Simple Somatic Symptom Disorder (SSSD) – a separate diagnosis that had been introduced for the second draft, with criteria requiring fewer symptoms than for a diagnosis of CSSD and shorter chronicity.

In order to accommodate SSSD, criteria and Severity Specifiers for CSSD have been modified since the second draft. (More on this in the next post.)

Since CSSS (or SSD, as is now proposed) did not exist as a category in DSM-IV, or in ICD-10 or DSM-III, it’s unclear and unexplained by the table what data for which existing somatoform disorders have been used for Kappa comparison for this new category with data for ICD-10 and DSM-III, and how meaningful comparison between them would be.

You can find out more about how the field trials were conducted on the DSM-5 Development site.

 

Delay in publication of field trial results and no key documents in support of proposals

Stakeholders may not get to scrutinise a report on the field trials until as late as a couple of weeks before the public comment period closes.

There are no Disorder Descriptions and Rationale/Validity Propositions PDF documents that expand on category descriptions and rationales (at least not for the Somatic Symptom Disorders) and reflect revisions to proposals between the release of the second and third draft.

Yesterday, I contacted APA’s Communications and Media Office to enquire whether the Somatic Symptom Disorders work group intends to publish either a Disorder Descriptions or Rationale/Validity Propositions document, or both, to accompany this latest draft during the life of the stakeholder review period or whether these key documents are being dispensed with for the third draft.

I’ll update if and when APA Media and Communications provides clarification.

 

Related post:

Make Yourself Heard! says DSM-5’s Kupfer – but are they listening?

Filed under Criticism of DSM-V, DSM-5, DSM revision process, DSM-5, DSM-5 consultation, DSM-5 draft proposals, DSM-5 field trials, DSM-5 in the media, DSM-5 third draft, Somatic Symptom Disorder, Somatoform Disorders Tagged with , , , , , , , , ,

Make Yourself Heard! says DSM-5’s Kupfer – but are they listening?

May 6, 2012 by

Make Yourself Heard! says DSM-5’s Kupfer – but are they listening?

Post #166: Shortlink: http://wp.me/pKrrB-26L

Four further commentaries from 1 boring old man on DSM-5 field trial results and Kappa values:

major depressive disorder κ=0.30?…

May 6, 2012

a fork in the road…

May 7, 2012

Village Consumed by Deadly Storm…

May 8, 2012

box scores and kappa…

May 8, 2012

MedPage Today

Most DSM-5 Revisions Pass Field Trials

John Gever, Senior Editor | May 07, 2012

“…Darrel Regier, MD, the APA’s research director, explained that the trials were intended primarily to establish reliability – that different clinicians using the diagnostic criteria set forth in the proposed revisions would reach the same diagnosis for a given patient. The key reliability measure used in the academic center trials was the so-called intraclass kappa statistic, based on concordance of the “test-retest” results for each patient. It’s calculated from a complicated formula, but the essence is that a kappa value of 0.6 to 0.8 is considered excellent, 0.4 to 0.6 is good, and 0.2 to o.4 “may be acceptable.” Scores below 0.2 are flatly unacceptable.

Kappa values for the dozens of new and revised diagnoses tested ranged from near zero to 0.78. For most common disorders, kappa values from tests conducted in the academic centers were in the “good” range:

Bipolar disorder type I: 0.54
Schizophrenia: 0.46
Schizoaffective disorder: 0.50
Mild traumatic brain injury: 0.46
Borderline personality disorder: 0.58

In the “excellent” range were autism spectrum disorder [0.69], PTSD [0.67], ADHD [0.61], and the top prizewinner, major neurocognitive disorder [better known as dementia], at 0.78. But some fared less well. Criteria for generalized anxiety disorder, for example, came in with a kappa of 0.20. Major depressive disorder in children had a kappa value of 0.29. A major surprise was the 0.32 kappa value for major depressive disorder. The criteria were virtually unchanged from the version in DSM-IV, the current version, which also underwent field trials before they were published in 1994. The kappa value in those trials was 0.59.

But a comparison is not valid, Regier told MedPage Today…”

Read full report

DSM5 in Distress
The DSM’s impact on mental health practice and research.

Newsflash From APA Meeting: DSM 5 Has Flunked its Reliability Tests
Needs To Be Kept Back For Another Year

Allen J. Frances, M.D. | May 6, 2012

“…The results of the DSM 5 field trials are a disgrace to the field. For context, in previous DSM’s, a diagnosis had to have a kappa reliability of about 0.6 or above to be considered acceptable. A reliability of .2-4 has always been considered completely unacceptable, not much above chance agreement…”

Reconstructed from data published by A Frances, DSM 5 in Distress, Psychology Today, 05.06.12

“…No predetermined publication date justifies business as usual in the face of these terrible Field Trial results (which are even more striking since they were obtained in academic settings with trained and skilled interviewers, highly selected patients, and no time pressure. The results in real world settings would be much lower). Reliability this low for so many diagnoses gravely undermines the credibility of DSM 5 as a basis for administrative coding, treatment selection, and clinical research…”

Read full commentary

Scientific American

Field Tests for Revised Psychiatric Guide Reveal Reliability Problems for Two Major Diagnoses

Ferris Jabr | May 6, 2012

“…The kappa for generalized anxiety disorder was about 0.2 and the kappa for major depressive disorder was about 0.3.

“…These numbers are way too low according to the APA’s own scales—and they are much lower than kappas for the disorders in previous versions of the DSM. Regier and other members of the APA emphasized that field trial methodology for the latest edition is far more rigorous than in the past and that kappas for many diagnoses in earlier editions of the DSM were likely inflated. But that doesn’t change the fact that the APA has a problem on its hands: its own data suggests that some of the updated definitions are so flawed that only a minority of psychiatrists reach the same conclusions when using them on the same patient. And the APA has limited time to do something about it…”

“…Until the APA officially publishes the results of the field trials, nobody outside the association can complete a proper analysis. What I have seen so far has convinced me that the association should anticipate even stronger criticism than it has already weathered. In fairness, the APA has made changes to the drafts of the DSM-5 based on earlier critiques. But the drafts are only open to comment for another six weeks. And so far no one outside the APA has had access to the field trial data, which I have no doubt many researchers will seize and scour. I only hope that the flaws they uncover will make the APA look again—and look closer…”

Read full report

Psychiatric News | May 04, 2012
Volume 47 Number 9 page 1a-28
American Psychiatric Association
Professional News

DSM Field Trials Providing Ample Critical Data

David J. Kupfer, M.D.

This article is part a series of commentaries by the chair of the DSM-5 Task Force, which is overseeing the manual’s development. The series will continue until the release of DSM-5 in May 2013.

As of this month, the 12-month countdown to the release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) officially begins. While the developers of DSM-5 will continue to face several deadlines over the coming year, the progress that has been made since APA’s 2011 annual meeting has been nothing short of remarkable.

One of the most notable and talked-about recent activities of the DSM revision concerns the implementation and conclusion of the DSM-5 Field Trials, which were designed to study proposed changes to the manual…

Read on

From the same article and note that

“After the comment period closes, visitors will no longer be able to submit feedback through the site, and the site will not reflect any further revisions to the draft manual in anticipation of its publication in May 2013. However, the site will remain live and viewable.”

Make Yourself Heard!

The DSM-5 Web site (www.dsm5.org) is open to a third and final round of feedback. For six weeks, patients and their loved ones, members of the profession, and the general public can submit questions and comments via the Web site. All will be read by members of the appropriate DSM-5 work groups.

A summary of changes made to the draft diagnostic criteria since the last comment period (May-July 2011) will help guide readers to important areas for review, but visitors are encouraged to comment on any aspect of DSM-5. After the comment period closes, visitors will no longer be able to submit feedback through the site, and the site will not reflect any further revisions to the draft manual in anticipation of its publication in May 2013. However, the site will remain live and viewable.

Psychiatrists can use this important opportunity to express their opinions about proposed changes and how they may impact patient care. Since http://www.dsm5.org was first launched in February 2010, the work groups have discussed— and in many cases, implemented draft changes in response to—the feedback received from the site. This final comment period presents a historic opportunity for APA members to take part in the DSM-5 revision process and help impact the way in which psychiatric disorders are diagnosed and classified in the future.

David J. Kupfer, M.D., is chair of the DSM-5 Task Force and a professor of psychiatry at the University of Pittsburgh Medical Center and Western Psychiatric Institute and Clinic.

Commentary on Dr Kupfer’s report from 1 boring old man

self-evident…

I boring old man | May 6,  2012

Further commentary from 1 boring old man on DSM-5 controversy

not a good time…

1 boring old man | May 5, 2012

Filed under American Psychiatric Association (APA), Criticism of DSM-V, DSM-5, DSM revision process, DSM-5, DSM-5 consultation, DSM-5 draft proposals, DSM-5 field trials, DSM-5 Petitions, DSM-5 third draft, DSM-5 timeline Tagged with , , , , , , , , ,

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