Patient submissions to third and final DSM-5 stakeholder review

Patient submissions to third and final DSM-5 stakeholder review

Post #182 Shortlink: http://wp.me/pKrrB-2f5

This third and final stakeholder review is scheduled to close on Friday. If an extension is announced I will update.

As with the two previous draft reviews, in 2010 and 2011, I am collating copies of submissions on these pages.

If you have submitted to the Somatic Symptom Disorder proposals or are a professional, professional body or advocacy organization that has submitted a general response which includes reference to the  Somatic Symptom Disorder proposals I would be pleased to receive a copy for publication on this site. Submissions will be published subject to review and posted in PDF format if more than a few pages long.

The most recent submission received is from “US patient 1”. This is a detailed response which I am publishing in both text and PDF format. (Note that as far as I can see submissions can only be uploaded to the DSM-5 Development site using the RT or html text editor and not as file attachments.)

Submission from US patient 1 to J 00 SSD and J 02 Conversion Disorder (FNSD)

Full text in PDF:    DSM-5 submission

To: DSM-5 Task Force, Somatic Symptom Disorders Work Group
From: _______
Re: Response on the Proposals for Somatic Symptom Disorder and Conversion Disorder
Date: June 12, 2012

The DSM-5 Task Force has thus far failed to address the conceptual and practical problems inherent in DSM-IV somatoform disease constructs. Specifically, its proposals for Somatic Symptom Disorder and Conversion Disorder are actually more flawed than their equivalents in DSM-IV. The criteria for these two diagnoses rely excessively upon purely subjective judgments by clinicians and on the extent of a clinician’s awareness of known diseases, and lack the specificity required of valid diagnostic constructs.

To understand just how strongly subjectivity of clinical interpretation can impact diagnostic outcome when using somatoform disorder criteria on a disease with unknown etiology, it is instructive to consider in some detail Johnson et al’s “Assessing Somatization Disorder in Chronic Fatigue Syndrome”1, a study on the reliability of DSM-III-R somatization disorder (SD) criteria and related instruments when applied to patients with chronic fatigue syndrome (CFS). As the DSM-III-R SD diagnostic construct was less subjective and had greater specificity in terms of symptom presentation than the proposed SSD criteria, a careful examination of its flaws, as demonstrated by this study, offers a sobering perspective on real world application of SSD criteria.

CFS is a somatic disease of unestablished etiology; the United States Centers for Disease Control has stated that “Research shows that CFS is not a form of psychiatric illness” and that an essential criterion for its diagnosis is “severe chronic fatigue of 6 months or longer that is not explained by any medical or psychiatric diagnosis”. Nevertheless, in spite of such evidence, an opinion persists in the medical community that CFS is in some way a psychosomatic illness, an opinion which can easily influence clinicians in their diagnoses of patients who satisfy CFS criteria. Thus, as Johnson et al noted: “Whether or not symptoms of CFS are considered medically caused will strongly affect the incidence of SD within the CFS population…If the examiner recognizes that the patient’s CFS symptoms indicate a physical illness, the diagnosis of SD may not be made. Conversely, if the examiner does not consider CFS a medical illness, the patient’s symptom endorsement may lead to the diagnosis of SD.”

To begin with, Johnson et al discussed the problems with the DSM-III-R criteria for somatization disorder:

“According to DSM-III-R .. the diagnosis of somatization disorder (SD) requires a person to present with at least 13 symptoms for which no significant organic pathology can be found. The symptoms must have caused the person to take medication, to see a physician, or to have altered her/his lifestyle. The disorder begins before the age of 30 and has a chronic but fluctuating course. However, the diagnosis of SD is extremely problematic in terms of its validity because it involves a series of judgments that can be arbitrary and subjective […] Specifically, the interviewer must decide if the symptom reported is attributable to an identifiable medical illness. Although such judgments are extremely difficult to make uniformly, the influence of bias introduced by the interviewer’s orientation on the prevalence of SD has not been adequately addressed.”

They noted the high variation between the estimates of SD prevalence in CFS patient cohorts reported by previous studies and concluded that it was “in itself indicative of the problem in defining SD”. They further pointed out that “The difficulty in distinguishing among somatic symptoms that are psychiatric vs. organic in origin can result in overdiagnosis of SD in medical illness, particularly chronic illness”, as they had observed in several studies by other authors on somatization in CFS.

Final 2 days: Submissions to third DSM-5 stakeholder review

 

Final 2 days for Submissions to third DSM-5 stakeholder review

Post #181 Shortlink: http://wp.me/pKrrB-2eX

There are only Thursday and Friday left before this third and final stakeholder review of proposals for DSM-5 categories and diagnostic criteria closes.

APA has failed to publish “full results” of its field trials – obliging professional, patient and public stakeholders to submit comment without the benefit of scrutinizing field trial data. That’s another APA schedule missed.

If any extension to the comment period is announced I will update.

The DSM-5 Development site has been slow to load, today, probably due to volume of traffic for both US and UK visitors and in some cases, not loading at all. If you are having problems try pulling up a page other than the Home Page and allow several minutes to load.

As with the two previous reviews, I am collating copies of submissions on these pages.

If you have submitted to the Somatic Symptom Disorder proposals or are a professional, professional body or advocacy organization that has submitted a general response which includes reference to the  Somatic Symptom Disorder proposals I would be pleased to receive a copy for publication on this site, subject to review, and posted in PDF format if more than a few pages long.

The most recent published submission is from “Joss”:

Submission from UK patient, Joss

I am writing to voice my concerns concerning the proposed category of Somatic Symptom Disorder.

Theoreticians of illness classification such as yourselves should be aware of the actual harm that could be caused to real people should this category be included in the DSM.

I would like to focus your minds with a real world example of how such a label might cause actual harm:

In 1998 I hurt my back. A scan showed a herniated disc but no further action was considered necessary. For the next three years my life was devastated by pain, I had bedsores and was pissing myself in bed from being unable to move. I believe that this was not taken seriously because I already had a pre-existing diagnosis of ME/CFS. The disbelief around my ME/CFS had already caused me problems obtaining the necessary help from medical services.

I believe that doctors thought I was ‘catastrophising’ and that had the SSD label been available to them they would have been able to categorise me as having:

‘Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns’

and, further, apply the three following highly subjective statements to me:

(1) Disproportionate and persistent thoughts about the seriousness of one’s symptoms.

(2) Persistently high level of anxiety about health or symptoms

(3) Excessive time and energy devoted to these symptoms or health concerns

I had CBT via a pain clinic but things got progressively worse. The CBT was of no help because it can not mend discs. I was, I admit, by this time feeling a tad suicidal because nobody would listen to me or believe that things were as bad as they were.

In 2001 I called an ambulance and went to the emergency department. The doctor was fine until he consulted my notes and saw I had an ME/CFS diagnosis. I was given morphine and they wanted to send me home.

It was only by refusing to leave that I gained admission to the hospital where a further scan was undertaken and it was found that a piece of disc had got in to my spinal canal and was pressing on my spinal cord. The next day I was in surgery and told that I would have been paralysed for life without it.

I would like you to reflect on how much worse the situation might have been if I had also been labelled as having SSD and on what happens when the SSD label is wrongly applied.

If someone is very ill and in pain is it not normal to feel distressed? How much distress is too much? Who decides what the right amount of distress for any given situation is?

What does ‘disproportionate’ mean in such a situation?

Is feeling anxious about such things not simply a normal and sane reaction to such circumstances?

And as for ‘excessive time and energy’ – well being bedridden and unable to move for whatever reason makes it a little hard to think of much else for much of the time.

To take such a lack of understanding of subjective experience of severe physical symptoms and construct a spurious and vague illness category from them is not only philosophically flawed it is dangerous to those who may be labelled in such a way.

This definition is far too vague and leaves far too much room for definitional ‘creep’, misinterpretation, misuse and even abuse.

It could certainly lead to possible missed diagnosis should a patient be placed in the SSD group and then continually disbelieved because of the label and left with no hope of getting to the bottom of the problem. To leave people without hope can only be called cruel

I am concerned that many illnesses such as ME/CFS, fibromyalgia and pain syndromes, and back problems which are often hard to diagnose and treat and can be a considerable burden to those who have to live with them will get drawn into the SSD basket and that, once there, patients will lose all hope of receiving any appropriate bio-medical treatment.

I am sure you are aware that medicine does move forward and that many illnesses once defined as psychiatric or psychological or simply beyond the reach of scientific clarity are now no longer considered ‘medically unexplained’. Just because there is currently no ‘medical’ explanation for a specific symptom and no understanding of how somebody might experience that symptom does not automatically render it a problem for psychology or psychiatry.

DSM-5 controversy: Lane on “SAD”, Frances Follows the Money, Spitzer et al on Kappa reliability

DSM-5 controversy round up:

Lane on “SAD”; Frances “Follows the Money”; Spitzer et al on Kappa reliability; A Closer Look at Pending Changes to the Future of Psychiatric Diagnosis June issue The Journal of Nervous and Mental Disease

Post #178 Shortlink: http://wp.me/pKrrB-2em

Side Effects at Psychology Today

From quirky to serious, trends in psychology and psychiatry.

Christopher Lane, Ph.D. | June 11, 2012

Naming an Ailment: The Case of Social Anxiety Disorder”

“Social phobia” vs. “Social anxiety disorder”: What’s in a name?

…“Using data collected from a telephone survey of residents of New York State,” the letter writers continue, “we investigated whether the disorder name affects the perceived need for treatment. Random-digit dialing was used to obtain phone numbers … In total, 806 people participated.”

“Respondents heard a brief vignette describing a person who experiences discomfort in social situations and often avoids social events. These symptoms were labeled as either social phobia or social anxiety disorder, and respondents indicated whether the person should seek mental health treatment.”

The results are dubious to say the least…

Read full commentary

Psychology Today

DSM 5 in Distress | Allen Frances

Follow The Money
APA puts publishing profits above public trust

Allen Frances MD | June 11, 2012

…APA treats DSM-5 like a valuable publishing property, not as a public trust that importantly impacts on people’s lives and public policy. It is excellent at protecting its “intellectual property” with confidentiality agreements and at protecting its trademark and copyright with bullying threats of law suits. But APA has been sadly incompetent and wildly profligate in the day-to-day work of actually producing a safe and scientifically sound DSM-5.

Dr Scully is asking us to believe ten very unbelievable things. My view – if you want to understand why an unreliable and unsafe DSM-5 is being rushed prematurely to market – is to “follow the money…”

Read full commentary at DSM-5 in Distress

Newswire

http://ajp.psychiatryonline.org/article.aspx?articleid=1109031

The American Journal of Psychiatry, VOL. 169, No. 5

Letters to the Editor | May 01, 2012

Standards for DSM-5 Reliability

Robert L. Spitzer, M.D.; Janet B.W. Williams, Ph.D.; Jean Endicott, Ph.D.
Princeton, N.J. New York City

Am J Psychiatry 2012;169:537-537. 10.1176/appi.ajp.2012.12010083

TO THE EDITOR: In the January issue of the Journal, Helena Chmura Kraemer, Ph.D., and colleagues (1) ask, in anticipation of the results of the DSM-5 field trial reliability study, how much reliability is reasonable to expect. They argue that standards for interpreting kappa reliability, which have been widely accepted by psychiatric researchers, are unrealistically high…

A Closer Look at Pending Changes to the Future of Psychiatric Diagnosis

Released: 6/7/2012 9:00 AM EDT
Source: Wolters Kluwer Health: Lippincott Williams & Wilkins

Articles Have Potential to Affect Final DSM-5 Standards as Public comment Period Ends

Newswise — New York, NY (June 7, 2012) – The June issue of The Journal of Nervous and Mental Disease (JNMD) features a special section focused on the impending release of the revised Diagnostic and Statistical Manual of Mental Disorders (DSM-5), an update to psychiatric diagnosis standards. JNMD is published by Lippincott Williams & Wilkins, part of Wolters Kluwer Health.

The Journal of Nervous and Mental Disease Editor-in-Chief John A. Talbott, MD, (a past APA president and DSM-III collaborator) comments in his editorial, “The timing of this special section on DSM-5, therefore, is particularly auspicious because it provides the potential for these articles to affect the final DSM-5 decisions.” The DSM-5 manual, currently scheduled for publication in May 2013, is going through its final public comment period through June 15, 2012.

Many articles within the section present criticisms of DSM-5 proposals. Specifically, several authors worry that the new DSM-5 standards may open up more opportunities for false-positives – a doctor diagnosing a condition when it is not present, or providing medication when it is not needed.

• “Diagnostic Inflation: Causes and Suggested Cure” by Batstra and Frances displays the authors’ concern that the proposed changes to DSM-5 will result in diagnostic inflation and inappropriate use of medication. They suggest “stepped diagnosis,” which includes a watch-and-wait period before beginning medication, to combat false-positives.

• In “Recurrence of Bereavement-Related Depression: Evidence for the Validity of the DSM-IV Bereavement Exclusion From the Epidemiological Catchment Area Study,” Wakefield and Schmitz contend that the DSM-5 proposal to remove the bereavement exclusion from the definition of a major depressive episode would cause those who are experiencing normal grief after the death of a loved one to be mislabeled as clinically depressed.

Other articles respond to DSM-5 proposals to include new disorders and diagnostic constructs. For example, DSM-5 proposes to reclassify pathological gambling as a behavioral addiction, which may pave the way for other excessive behaviors to be included in this construct in the future.

• Mihordin takes a look at the potential consequences of this change in his article, “Behavioral Addiction V Quo Vadis?” in which he presents hypothetical criteria for the diagnosis of pathological model railroading disorder.

• Good and Burstein respond to the DSM-5 proposal to include a hebephilic subtype to the diagnosis of pedophilia in “Hebephilia and the Construction of a Fictitious Diagnosis”. Additionally, Wakefield examines two DSM-5 proposals on classifying pathological forms of grief as mental disorders in “Should Prolonged Grief Be Reclassified as a Mental Disorder in DSM-5? Reconsidering the Empirical and Conceptual Arguments for Complicated Grief Disorder.”

Included in the special section, “Psychotropic Marketing Practices and Problems: Implication for DSM-5” by Raven and Perry looks at how certain aspects of DSM-5 could be used by the pharmaceutical industry as marketing tools, especially with a wider customer base resulting from false-positive patients. In “A Critique of the DSM-5 Field Trials,” Jones examines problems that may have compromised the usefulness of the DSM-5 field trials.

It is important to note that the articles in the special section of JNMD were written at various points since February 2010 based on the criteria sets posted on the DSM-5 website. Many of these criteria sets have been updated since their initial posting. “Thus, the critiques of certain proposals contained in these articles may no longer be fully relevant to what is actually being proposed for DSM-5,” Dr. Talbott states in his editorial. Visit the DSM-5 website at http://www.dsm5.org/  for the most accurate information on what is being considered for inclusion in DSM-5.

# # #

About The Journal of Nervous and Mental Disease
Founded in 1874, The Journal of Nervous and Mental Disease is the world’s oldest, continuously published independent scientific monthly in the field of human behavior. Articles cover theory, etiology, therapy, social impact of illness, and research methods

DSM-5 round-up: Lane on “DSM-5 Facts” site, Frances on DSM-5, Kupfer on Frances

DSM-5 round-up: Lane on new “DSM-5 Facts” site, Frances on DSM-5, Kupfer on Frances

Post #176 Shortlink: http://wp.me/pKrrB-2cQ

What we were waiting for were the “full results” of the reliability data from the DSM-5 field trials.

What we got was a public relations sticking plaster.

Christopher Lane reported in Side Effects on the American Psychiatric Association’s new platform DSM-5 Facts – a website launched, last week, to “correct the record, highlight key omissions – and provide essential perspective so that the public has a complete and accurate view…

Side Effects

Christopher Lane, Ph.D. | June 4, 2012

The APA’s PR Problem
Why is the American Psychiatric Association hiring a PR company to market DSM-5?

As the news tumbled out last week that the American Psychiatric Association had hired GYMR, an expensive PR company, to help the organization “execute strategies that include image and alliance building, public education campaigns or media relations to harness the formidable forces of Washington and produce successful results for clients” (services that GYMR brags about in its mission statement), it became clearer than ever that the APA has more than an image-problem with DSM-5

Read on

In a long interview with Allen Frances, Stephen M. Strakowski asks: What’s wrong with DSM-5 and what needs to be done to put it right?

Medscape Psychiatry

What’s Wrong With DSM-5?

Stephen M. Strakowski, MD; Allen J. Frances, MD | June 1, 2012

Addressing Prescription Drug Abuse: Introduction
The Biggest Problems With DSM-5?
What Would Dr. Frances Do?
A Safe, Credible DSM-5 by 2013?

…The reliability-test results for stage 1 show that DSM-5 badly flunked and that stage 2 is desperately needed. The leadership lowered expectations with statements indicating that they are willing to accept diagnostic agreements far below historical levels and include proposals achieving diagnostic agreements that are little better than chance. This is simply not acceptable and should not be accepted…

…it is discouraging that DSM-5 has not accepted the need for external review, is going forward with poorly written and unreliable criteria sets, and still contains so many unsafe and scientifically unsound proposals. It remains to be seen whether DSM-5 will be responsive to what is certain to be increasing external pressure to trim its sails and improve its quality. If it attempts to hang tough, I think DSM-5 will no longer be used much (if at all) overseas and will also lose much of its following in the United States…

Task Force Chair, David J. Kupfer, MD, responds:

Medscape Psychiatry

Dr. Kupfer Defends DSM-5

David J. Kupfer, MD | June 1, 2012

Editor’s Note:
In a recent Medscape interview with Dr. Stephen Strakowski, DSM-IV Task Force Chair Dr. Allen J. Frances expressed serious concerns about a number of proposals being considered for inclusion in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), scheduled for release in May 2013. Below, DSM-5 Task Force Chair Dr. David Kupfer defends the proposed revision.

A DSM-5 Defense
Will DSM-5 Inflate Prevalence?

A third Medscape report from the APA’s Annual Conference by Nassir Ghaemi, MD:

Medscape Psychiatry

DSM-5: Finding a Middle Ground

Nassir Ghaemi, MD | June 1, 2012

Professor of Psychiatry, Tufts University School of Medicine; Director, Mood Disorders Program, Psychiatry Department, Tufts Medical Center, Boston, Massachusetts

DSM-5: Validity vs Reliability
But DSM-IV Has Limitations, Too

Two more commentaries from 1 Boring Old Man on DSM-5 process and field trial Kappa results:

the APA Trustees must intervene in the DSM-5…

1 Boring Old Man | June 4, 2012

and will…

1 Boring Old Man | June 3, 2012

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

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

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

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

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