Wednesday, January 14, 2009

Diagnostic Controversy: the DSM-V in Progress...

I want to begin by saying I don't have any insider info into the process and I don't have an opinion about what's going on. Which is good, because no one asks me.

The DSM is a book that lists the guidelines for making psychiatric diagnoses. It's like a Chinese Menu--- a few symptoms from column A, a few symptoms from Column B, and voila, you've got Diagnosis X. There have been 4 versions to date, and the 5th is in the works.

It would be nice if we could run a definitive test and say, Yup, the Depression Factor is present in your blood, you've got Major Depression, single episode, and the level is 75 so it's "moderate." Or look, the left side of the amygdala is enlarged, therefore it's Panic Disorder. Or, the frontal region has increased metabolism when you burp, so you've got Paranoid Schizophrenia.

It doesn't work that way, we don't have any definitive tests and when we do tests in psychiatry as part of a diagnostic evaluation. It's to make sure the patient doesn't have a brain tumor or a stroke or thyroid dysregulation or hypoglycemia or some other medical condition (that we can see or measure) that explains the symptoms. If the brain looks anatomically normal, if the blood is normal, if there are no funny substances that explain why someone is acting or feeling either badly or weirdly, then by default, it's a psychiatric problem. Some day this may change, but right now that's it. Researchers are making progress towards finding links between psychiatric illnesses (after they are diagnosed as such) and specific genetics or brain metabolic differences, but they don't make a diagnosis and it's all pretty new.

So how are diagnostic criteria decided? A bunch of people sit in a room and decide. They talk, they look at research findings, they pool their experience, and actually I'm not all that sure (keep reading, there are some answers below). The issue of diagnostic criteria and validity is laden with emotion-- there are people who like psychiatric labels, like the drug companies. And there are people who don't like labels -- like those who don't want their sexual preferences or gender distress labeled an illness, Health insurance companies pick and choose what diagnoses they will reimburse for. So once upon a time, homosexuality was a psychiatric illness and it's not anymore.

The DSM-V work groups are in place and these peeps are talking about the next volume and what should change. There have been issues with the process of what they are doing-- the members of these groups signed a non-disclosure document, and my email (why me?) gets messages from people complaining that the process is too secretive, and other messages stating that there is a need for some confidentiality during the process, but it's open and transparent. Today's email came from the American Psychiatric Association, pointing me to a Wall Street Journal blog post about the issue, so I will guide you to that: Click Here.

Oh, and while you're clicking, Roy also posted on this issue back in November: Click Here.

Oh, and here's what the APA has to say about the how the process transpires:

The work groups began meeting in late 2007. While the 13 work groups reflect the diagnostic categories of psychiatric disorders in the previous edition DSM-IV, it is expected that those categories will evolve to better reflect new scientific understanding. With the understanding that some continuity from DSM-IV to DSM-V is desirable to maintain order in the practice of psychiatry and continuity in research studies, there has been no pre-set limitation on the nature and degree of change that work groups can recommend for DSM-V.

Each work group meets regularly, in person and on conference calls. They begin by reviewing DSM-IV’s strengths and problems, from which research questions and hypotheses are first developed and then investigated through literature reviews and analyses of existing data. They will also develop research plans, which can be further tested in DSM-V field trials involving direct data collection. In order to invite comments from the wider research, clinical, and consumer communities, the APA launched a DSM-V Prelude Web site in 2004, where these groups could submit questions, comments, and research findings to be distributed to the relevant work groups.

Based on this comprehensive review of scientific advancements, targeted research analyses, and clinical expertise, the work groups will develop draft DSM-V diagnostic criteria. A period of comment will follow, and the work groups will review submitted questions, comments, and concerns. The diagnostic criteria will be revised and the final draft of DSM-V will be submitted to the APA’s Council on Research, Assembly, and Board of Trustees for their review and approval. A release of the final, approved DSM-V is expected in May 2012.

You can read the whole APA web page about this: Click Here.


Mr Ian said...

One of the more exciting things I've seen in psychiatry lately is NeuroAnalyis -
- which looks to actually suggest a neuro-computational diagnostic testing process.

There is further reading at:

Hope you don't mind the links.

Rach said...

So does this mean that in theory, there could potentially be COMPLETELY different criteria set forth in order to be diagnosed with mental illnesses? In 2012, I might have to walk on my hands and cluck like a chicken for at least 4 1/2 minutes 2x a day, 3 days a week for at least 2 weeks in order to be diagnosed with mania? Or will I just need to remain hyper-sexual, with racing thoughts, unusual behavior outside my norm and reduced sleep (oh and maybe some hand walking and chicken clucking)?

Anonymous said...

Hi shrink rappers,

As a medical collegue, but non-psychiatrist, it is so very interesting to "eaves drop" on the internal machinations of your profession regarding the classification of disease.

Myself, for disease in general, I am quite concrete. I have to have a detailed understanding of how the organ of concern works normally. Then, when it goes wrong,I like to know what happens, be it a structural or ultra-structural level. Following this logical sequence, the clinical features are no surprise and the treatments are directed at identifiable targets.

This approach does not hold me in good stead for psychiatry.

Oh... but those neurotransmitters are awfully small and short-lived and synaptic activity is fleeting. Stroke...yes I understand.....GBM yes I understand...But at the connectivity level I have little understanding, it's grey to me

What I find so absolutely fascinating about psychiatry is what I call in my ignorance "greyness". I can't see it, I can't measure it, but the clinical features fall into recurring groups and they seem to respond to a particular kinds of medication / therapy.

I see the DSM IV (revised) currently as the best attempt to classify the greyness and from my point of view, while there are fuzzy areas, and points of contention it seems very comprehensive and robust even, to an outsider.

Ergo the diagnosis of lupus and the American Rheumatology Assoc list of major and minor criteria. That is also (if you boil it down to nuts and bolts) a shopping list.

It's great in medicine that there is need for the concrete and the grey and they together, are greater than the sum of the individual parts.

PS. In my lecture to the second year med students I have listed shrink rap to be checked out

Great site.. thanks guys.

Dinah said...

Mr. Ian, tx for the links
Rach: don't count on it.
Anon: thank you for the kind words and the med student blog traffic!

DrivingMissMolly said...

Anonymous medical colleague..somehow, I don't like your tone. You know, all the Shrink Rappers--Dinah, Roy and ClinkShrink--are all DOCTORS. Being psychiatrists doesn't make them less so and so they should not be treated as such.

On another note--

Question: Do you or are you (Shrink Rappers) willing to discuss a patient diagnosis WITH the patient?

My psychiatrists have balked. I only found out about the lovely personality disorder by accident. Current psychiatrist doesn't seem to want to delve into my various diagnoses and I don't understand why. He seems to just want me to, um, talk, but for $200 a session, I want structure and concrete information.

Also, how many DXs can one have? It seems like Borderline personality disorder, GAD, MDD and Bipolar 2 is excessive.


Dr. Todd Finnerty, Psy.D. said...

Theres always someone writing a book ;) and mine is actually about the concept of Depressive Personality Disorder which was included "for further research" in DSM-IV and an example of just one of the many issues the DSM-V task force will have to deal with. In researching the book I've found myself getting more and more involved in postmodern approaches and the way we treat psychiatric diagnoses in general. Rach questioned if there could "potentially be COMPLETELY different criteria..." and I think we should expect changes- the degree of which of course depending on the area. There is a lot of talk of dimensional vs categorical approaches particularly to personality disorders as well as fine tuning the way we express functional impairment, etc. I don't think we necessarily need to hide the process as if it were like selecting a pope however, we should be able to come to terms as the anonymous poster said with the fact that there is a lot of "greyness" and the gaps will need to be filled in a manner that hopefully does not sacrifice clinical utility ;) The shameless plug for my book:

Anonymous said...

There wouldn't be a problem with the DSM or even with the lack of transparency (though...why?) if everyone got that these labels are basically there for the sake of expediency and consistency and nothing more.

Nobody knows what the hell these "disorders" are - and while the people writing the book may get that - everyone else points to the DSM as if it's the inerrant word of Science. It's not, it's just so that when people talk about "major depression" vs. "dysthymia" vs. "whateverthehell" everyone is using the same definition (sort of).

Anonymous said...

Driving Miss Daisy,

I'm sorry that you did not like my tone.

What I was trying to say, and it may have got lost in rambliness, is that I, basically, am in awe of psychiatry. I know that they are DOCTORS and more than that, highly trained specialists with a wealth of experience between them. They make a HUGE difference in the lives of their patients. That I don't have a great grasp of psychopathology, is my shortcoming.

Lucky us to share their pearls of wisdom, delivered with such enthusiasm and humor.

Anonymous said...

The Diagnostics and Statistical Manual, the Shrink's bible, has been around for over 50 years, and now possibly contains nearly 300 mental disorders. Many are created and added to the DSM as each new edition is created. On occasion, a mental disorder is deleted from the DSM, such as homosexuality in the early 1970s.

Published by the APA, it is also used, I understand, for seeking mental diagnostic criteria to assure reimbursement. The DSM is also often used as a reference to validate suspected assessments by the psychiatrist and the DSM is organized by the following:

I- Mental disorders
II- mental conditions
III- Physical disorders/syndromes, medical conditions (co-morbidity)
IV- Mental disorder suspected etiology
V- Pediatric assessments

The APA is creating the next DSM, DSM-V, and has had its task force members assigned to this next DSM edition sign non-disclosure agreements, which is rather absurd and pointless. Lack of transparency equals lack of credibility because of these agreements of the content of the next DSM. It opposes any recovery model necessary regarding such disorders, I believe.

The DSM should be evaluated by another unrelated task force or a peer review of sorts to assure objectivity. This is particularly of concern presently, as many more are diagnosed with mental dysfunctions presently at an alarming rate- children in particular,

Dan Abshear

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