Wednesday, January 05, 2011

The DSM-5 Controversy


I've followed in bits & pieces. Sometimes for Shrink Rap, sometimes because the issues fill my email in-box, sometimes because there's no escape. Oh, and lots of the players have familiar names.

In the December 27th issue of Wired, Gary Greenberg writes a comprehensive article on the debates around the revision of the American Psychiatric Association's upcoming revision of the Diagnostic and Statistical Manual. So, "Inside the Battle to Define Mental Illness." Do read it. Here's a quote:

I recently asked a former president of the APA how he used the DSM in his daily work. He told me his secretary had just asked him for a diagnosis on a patient he’d been seeing for a couple of months so that she could bill the insurance company. “I hadn’t really formulated it,” he told me. He consulted the DSM-IV and concluded that the patient had obsessive-compulsive disorder.

“Did it change the way you treated her?” I asked, noting that he’d worked with her for quite a while without naming what she had.

“No.”

“So what would you say was the value of the diagnosis?”

“I got paid.”

As scientific understanding of the brain advances, the APA has found itself caught between paradigms, forced to revise a manual that everyone agrees needs to be fixed but with no obvious way forward. Regier says he’s hopeful that “full understanding of the underlying pathophysiology of mental disorders” will someday establish an “absolute threshold between normality and psychopathology.” Realistically, though, a new manual based entirely on neuroscience—with biomarkers for every diagnosis, grave or mild—seems decades away, and perhaps impossible to achieve at all. To account for mental suffering entirely through neuroscience is probably tantamount to explaining the brain in toto, a task to which our scientific tools may never be matched. As Frances points out, a complete elucidation of the complexities of the brain has so far proven to be an “ever-receding target.”

What the battle over DSM-5 should make clear to all of us—professional and layman alike—is that psychiatric diagnosis will probably always be laden with uncertainty, that the labels doctors give us for our suffering will forever be at least as much the product of negotiations around a conference table as investigations at a lab bench. Regier and Scully are more than willing to acknowledge this. As Scully puts it, “The DSM will always be provisional; that’s the best we can do.” Regier, for his part, says, “The DSM is not biblical. It’s not on stone tablets.” The real problem is that insurers, juries, and (yes) patients aren’t ready to accept this fact. Nor are psychiatrists ready to lose the authority they derive from seeming to possess scientific certainty about the diseases they treat. After all, the DSM didn’t save the profession, and become a best seller in the bargain, by claiming to be only provisional.

7 comments:

Anonymous said...

Dinah,
I found the article on the collar bomber, also in that issue, to be a much better read.
LSD

pj1280 said...

I wrote about this article on my blog, too, and even excerpted the same passage. While some might look at this psychiatrist as simply exploiting the DSM (and the patient) to make a buck, the truth is that the only real use of the DSM codes is to give an insurance company or other payor some justification for the visit.

In my opinion, no psychiatrist should hold the DSM-IV (or 5, or 6, or 7, or however many editions we ultimately get) as providing a definition of psychiatric illness. It's a rough guide and will never be anything more, even if we someday have the genetic or imaging "test" for each diagnosis.

I'm in the camp that says "just scrap it." Too many smart people are wasting too much time and money creating this document that, at best, will standardize care that shouldn't be standardized, and, at worst, will destroy our field. From the inside, unfortunately.

Zoe Brain said...

It also provides a justification for an insurer *not* to pay for the visit, in some cases.

Or to justify discrimination in employment, because although it's a mental illness, it's not, it's a moral failing.

Example: Americans with Disabilities Act
Sec. 12211. Definitions
(b) Certain conditions
Under this chapter, the term "disability" shall not include
(1) transvestism, transsexualism, pedophilia, exhibitionism, voyeurism, gender identity disorders not resulting from physical impairments, or other sexual behavior disorders;

Thus a diagnosis under 302.85 will not only trigger an insurer's automatic exclusion of treatment related to GID, but also mean the "mental illness" is considered a moral issue not a disability.

From Psychiatric News February 20, 2009 Volume 44, Number 4, page 13:

The remaining symposium, "In or Out? A Discussion About Gender Identity Diagnoses and the DSM," will focus on diagnostic issues specific to gender identity disorder, particularly the issues of having gender identity disorder listed in DSM-V and the implications of removing it.

Several leaders in the transgender community will speak at this symposium.

S6. "In or Out?": A Discussion About Gender Identity Diagnoses and the DSM (DSM Track DM03)

1. The DSM-V Revision Process: Principles and Progress William E. Narrow, M.D.
2. Beyond Conundrum: Strategies for Diagnostic Harm Reduction Kelley Winters, Ph.D.
3. Aligning Bodies With Minds: The Case for Medical and Surgical Treatment of Gender Dysphoria Rebecca Allison, M.D.
4. The Role of Medical and Psychological Discourse in Legal and Policy Advocacy for Transgender Persons in the U.S. Shannon P. Minter, J.D.

When the factual question of whether a medical syndrome should be in a psychiatric diagnostic manual depends on political considerations - then we have a problem.

The whole idea of having GID listed was so it would be a recognised medical condition, and treatment paid for and allowances made in employment, as per any other medical condition.

Unfortunately, despite resolutions by the APA, AMA etc, very few insurance policies cover it, and it is used as an excuse to deny payments for broken legs (the theory being that hormonal treatment might lead to brittle bones) etc.

Zoe Brain said...

It also provides a justification for an insurer *not* to pay for the visit, in some cases.

Or to justify discrimination in employment, because although it's a mental illness, it's not, it's a moral failing.

Example: Americans with Disabilities Act
Sec. 12211. Definitions
(b) Certain conditions
Under this chapter, the term "disability" shall not include
(1) transvestism, transsexualism, pedophilia, exhibitionism, voyeurism, gender identity disorders not resulting from physical impairments, or other sexual behavior disorders;

Thus a diagnosis under 302.85 will not only trigger an insurer's automatic exclusion of treatment related to GID, but also mean the "mental illness" is considered a moral issue not a disability.

From Psychiatric News February 20, 2009 Volume 44, Number 4, page 13:

The remaining symposium, "In or Out? A Discussion About Gender Identity Diagnoses and the DSM," will focus on diagnostic issues specific to gender identity disorder, particularly the issues of having gender identity disorder listed in DSM-V and the implications of removing it.

Several leaders in the transgender community will speak at this symposium.

S6. "In or Out?": A Discussion About Gender Identity Diagnoses and the DSM (DSM Track DM03)

1. The DSM-V Revision Process: Principles and Progress William E. Narrow, M.D.
2. Beyond Conundrum: Strategies for Diagnostic Harm Reduction Kelley Winters, Ph.D.
3. Aligning Bodies With Minds: The Case for Medical and Surgical Treatment of Gender Dysphoria Rebecca Allison, M.D.
4. The Role of Medical and Psychological Discourse in Legal and Policy Advocacy for Transgender Persons in the U.S. Shannon P. Minter, J.D.

When the factual question of whether a medical syndrome should be in a psychiatric diagnostic manual depends on political considerations - then we have a problem.

moviedoc said...

Did the former president of APA mean, "I got paid by insurance."? Seems to me insurers mostly require ICD codes and will not accept DSM codes anyway.

pj1280 said...

moviedoc, DSM codes are acceptable ICD codes: http://bit.ly/hqyIhH

Lois Holzman said...

I also have been writing abut this on my blog loisholzman.org, raising the broader issue of the proglems with the diagnositic way of life (beyond the issue of OVER diagnosing) and suggesting if diagnosis must be doe, it should be done democratically.
Lois Holzman