Grantham University Psychopathology Social Work Discussion Paper

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A diagnosis is powerful in the effect it can have on a person’s life and treatment protocol. When working with a client, a social worker must make important decisions—not only about the diagnostic label itself but about whom to tell and when. In this Discussion, you evaluate the use and communication of a diagnosis in a case study.

To prepare: Focus on the complex but precise definition of a mental disorder in the DSM-5 and the concept of dimensionality both there and in the Paris (2015) and Lasalvia (2015) readings. Also note that the definition of a mental disorder includes a set of caveats and recommendations to help find the boundary between normal distress and a mental disorder.

Then consider the following case:

    Ms. Evans, age 27, was awaiting honorable discharge from her service in Iraq with the U.S. Navy when her colleagues noticed that she looked increasingly fearful and was talking about hearing voices telling her that the world was going to be destroyed in 2020. With Ms. Evans’s permission, the evaluating [social worker] interviewed one of her closest colleagues, who indicated that Ms. Evans has not been taking good care of herself for several months. Ms. Evans said she was depressed.

    The [social worker] also learned that Ms. Evans’s performance of her military job duties had declined during this time and that her commanding officer had recommended to Ms. Evans that she be evaluated by a psychiatrist approximately 2 weeks earlier, for possible depression.

    On interview, Ms. Evans endorsed believing the world was going to end soon and indicated that several times she has heard an audible voice that repeats this information. She has a maternal uncle with schizophrenia, and her mother has a diagnosis of bipolar I disorder. Ms. Evans’s toxicology screen is positive for tetrahydrocannabinol (THC). The evaluating [social worker] informs Ms. Evans that she is making a tentative diagnosis of schizophrenia.

    Source: Roberts, L. W., & Trockel, M. (2015). Case example: Importance of refining a diagnostic hypothesis. In L. W. Roberts & A. K. Louie (Eds.), Study guide to DSM-5 (pp. 6–7). Arlington, VA: American Psychiatric Publishing.

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Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. PA R T I DIAGNOSTIC PRINCIPLES EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 1 Introduction The year 2013 marked the publication of DSM-5, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA). This was the first major revision in more than 30 years. Prior to 1980, diagnostic classification of mental disorders was an abstruse subject, of interest only to researchers and a few experts. But if mental disorders are medical diagnoses, they require a scientifically based classification. Moreover, since 1980, the DSM system has had a profound influence on all the mental health professions. The public, some of whom have been on the receiving end of a diagnostic process, also finds the subject fascinating, so revisions of psychiatry’s manual are front-page news. This book is a guide to the main features of the latest version of the manual. It will focus on three questions. First, what are the most important changes? Second, what are the implications of these changes for practice? Third, is DSM-5 better, worse, or equal to its predecessors? This book, as a critical guide for the intelligent clinician, will applaud the positive aspects of DSM-5 but underline its limitations. It will be supportive of some changes but be critical of others. What DSM-5 Can and Cannot Do The first two manuals published by APA, DSM-I (1952) and DSM-II (1968), did not have a great impact on psychiatry. They were used for statistical purposes, but they were not guides to clinical practice. 3 EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 4 | Part I Diagn ostic P ri n cip l e s In contrast, the third edition of the manual, DSM-III, published in 1980, was a major break with the past, as well as a best-selling book. The ideas behind this edition reflected a new paradigm for psychiatry, and the politics that made a radical revision possible are a fascinating story in their own right (Decker, 2013). DSM-III moved classification from clinical impressions to some degree of rigor. It increased reliability by taking an “atheoretical” position—that is, making diagnoses based on what clinicians can see and agree on as opposed to the abstract theories used in DSM-I and DSM-II. DSM-III, and its successors, found a place on the shelf of almost every psychiatrist, psychologist, and mental health professional. There were no major changes in the manual during the next 30 years. DSM-III-R, published in 1987, allowed a greater degree of overlap between diagnoses, and DSM-IV, published in 1994, added some important new diagnoses, including bipolar II disorder and attention-deficit hyperactivity disorder in adults. In 2000, a slightly edited version, DSM-IV-TR, appeared. The absence of major changes for so long could be seen as suggesting a need for a new system that could radically revise the diagnosis of mental disorders. This was the mandate given to the editors of DSM-5 by the APA. The work lasted 10 years, with a result that was initially claimed to be a “paradigm shift.” Is the DSM-5 system an improvement over previous editions? The answer has to be yes and no. One would like to believe so, but there are reasons for doubt. Some problems derive from the concept that psychopathology lies on a continuum with normality, making it difficult to separate mental disorders from normal variations and leading to a danger of overdiagnosis. Other issues derive from a strong attachment to the principle that mental disorders are brain disorders, even though knowledge is insufficient to develop a classification based on neuroscience. Although great progress has been made in research on the brain, the origins of mental illness remain a mystery. When one does not know enough, one should not invest in change for change’s sake. Sometimes it is better to keep a known system, however faulty, than make modifications with unpredictable EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 1 I n t ro d u c t i o n | 5 consequences. Moreover, even the smallest changes to diagnostic criteria can have profound effects on research and practice. Finally, revisions with good intentions can still lack clinical utility. Revising DSM is an enormous job, and each edition has grown larger, more complicated, and thicker. Yet much of what is written in the manual may never be applied in practice. The Validity of Psychiatric Diagnosis DSM-III aimed to make diagnosis more reliable, but reliability is not validity. During the next 33 years, constant use of the manuals gave clinicians the impression that their categories were valid. That was not true. The DSM system lacks the data to define mental disorders in the way that physicians conceptualize medical illnesses. Diagnoses in medicine can also be vague, but psychiatry is far behind other specialties in grounding categories in measurements that are independent of clinical observation. Almost all DSM-5 diagnoses are based entirely on signs and symptoms. Although some disorders have support for their validity, and although observation can be made more precise through statistical evaluation and expert consensus, most other areas of medicine use blood tests, imaging, or genetic markers to confirm impressions drawn from signs and symptoms. Psychiatry is nowhere near that level of knowledge. No biological markers or tests exist for any diagnosis in psychiatry. For this reason, any claim that DSM-5 is more scientific than its predecessors is unjustified. In 1980, I was a strong supporter of the paradigm shift introduced by DSM-III. It was progressive to make diagnosis dependent on observation rather than on theory. But this provisional stance became frozen in time, and progress during the succeeding decades has been slow. Radical changes in classification would require much more knowledge about the causes of mental disorders. And that is just what we do not have. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 6 | Part I Diagn ostic P ri n cip l e s Psychiatry and Neuroscience Psychiatry has bet on neuroscience as the best way to understand mental disorders, to solve problems in diagnosis, and to plan treatment interventions. Only time will tell how this wager will pan out. Some psychiatrists claim that the field is on the verge of a great breakthrough. If one were to believe the hype, a biological explanation—and a biological cure—for mental illness lies just around the corner. (Or as one wag put it, every few years we are told that answers are just a few years away.) Although progress in brain research has been rapid and impressive, its application to psychiatry has thus far been very limited. Brain scans are impressive (even if one keeps in mind that the colors are artificial), but all they tell you is that activity is different at different sites. The precise meaning of these changes is unclear, and none are specific to any diagnosis. We do not know enough about the brain, or about the mind, to develop a truly scientific classification, and it could be 50–100 years before we can even get close. It is understandable that psychiatry, so long the Cinderella of medicine and desperate for respectability, wanted to plant its flag on the terrain of neuroscience. But the promise of the 1990s (“the decade of the brain”) for research on mental disorders has not been fulfilled. Neuroscience has shed much light on how the brain functions, but we do not understand the etiology or the pathogenesis of severe mental disorders. We know that most are heritable, but we have no idea about which (or how many) genes are involved. Although some disorders are associated with abnormalities on brain imaging, the findings are neither specific nor explanatory. Although psychopathology can be associated with changes in neurotransmitters, the theory that chemical imbalances cause mental disorders is too simple or plain wrong. Ultimately, it may be impossible to fully explain mental disorders as brain disorders. The neuroscience model attempts to reduce every twisted thought to a twisted molecule, but it devalues studying the mind on a mental level. Considering that it will take many decades to unravel these mysteries, the current situation is nothing to be ashamed of. The DSM-5 EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 1 I n t ro d u c t i o n | 7 task force, as well as the leaders of the National Institute of Mental Health, believe that psychiatry should give up its traditional mission, which was both scientific and humanistic, and redefine itself as the clinical application of neuroscience. To paraphrase a famous line from the Vietnam War, they want to destroy psychiatry in order to save it. It is of course true that mental phenomena reflect the activity of the human brain. But the brain is the most complex structure known in the universe. There are more synapses in the brain than stars in the galaxy. This is a project for a century, not a decade, and its results may never provide a full explanation of mental illness. Unsolved Problems in Psychiatric Diagnosis Lack of Knowledge About Mental Disorders: DSM-5 is not “the bible of psychiatry” but, rather, a practical manual for everyday work. Psychiatric diagnosis is primarily a way of communicating about patients. This function is essential but pragmatic—categories of illness can be useful as heuristics without necessarily being “true.” The DSM system is a rough-and-ready classification that brings a degree of order to chaos. But it describes categories of disorder that are poorly understood and that will be replaced with time. Moreover, current diagnoses are syndromes, not true diseases. They are symptomatic variants of broader processes defined by arbitrary cutoff points. Thus, although classifications serve a necessary function, psychiatrists can only guess how “to carve nature at its joints.” That phrase (attributed to Aristotle) describes an impossible task. We do not know if it is possible to find joints to be carved. Even in medicine, diagnoses are not always cleanly defined or related to a specific etiology. In contrast, mental disorders greatly overlap with each other—and with normality. The Need for Biological Markers: In the absence of a more fundamental understanding of disease processes, DSM-5, like its predecessors, had no choice but to continue basing diagnostic criteria on signs and symptoms. But observation needs to be augmented by biological markers, as has been done in other medical specialties. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 8 | Part I Diagn ostic P ri n cip l e s In the absence of independent measures of this kind, we cannot be sure that any category in the manual is valid. We should not therefore think of current psychiatric diagnoses as “real” in the same way as medical diseases. Also, listing them in a manual does not make them real. For example, broad categories such as “major depression” in no way resemble diseases. Even the most “classical” concepts in psychiatry, such as the separation of schizophrenia from bipolar disorder, have not fully stood up to scrutiny. In summary, psychiatrists must make diagnoses, but they do not need to reify them. They are best advised to stay humble and to avoid hubris. Boundaries Between Mental Disorder and Normality: This is one of the most nagging problems in psychiatric diagnosis. Every edition of DSM has expanded this frontier, taking on increasingly more problems of living as diagnosable disorders. Psychiatric classification has become seriously overinclusive, and the manual grows ever larger with each edition. DSM-5 also errs on the side of expanding boundaries—mainly out of fear of “missing something” or not including problems that psychiatrists treat in practice. The result is that people with normal variations in emotion, behavior, and thought can receive a psychiatric diagnosis, leading to stigma and inappropriate and/or unnecessary treatment. Diagnostic Validity and Research: Because we have to live with a diagnostic system that is provisional—and that will almost certainly prove invalid in the long run—much of the research on mental disorders has to be taken with a grain of salt. For example, although a massive amount of data has been collected on the epidemiology of mental illness, almost all its findings are dependent on the current diagnostic system. Similarly, studies of treatment methods in psychiatry that target specific disorders are sorely limited by the problematic validity of categories. Most treatments, from antidepressants to cognitive behavioral therapy, have broad effects that are not specific to any diagnosis. Comorbidity: One of the most troubling problems with the DSM system is that it yields multiple diagnoses in the same patient. That is not the way medicine usually works. It is possible for patients to suffer from more than one disease. But in psychiatry, if you follow EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 1 I n t ro d u c t i o n | 9 the rules, the same symptoms can be used to support two or three diagnoses. Thus, “comorbidity” is little but an artifact of an inexact system in which criteria overlap. The sicker a patient, the more mental disorders will be identified. DSM-5 considered severity ratings and diagnostic spectra to address this problem, but these procedures could not resolve underlying questions about boundaries. Algorithmic Diagnosis: Another source of uncertainty is that diagnosis in psychiatry does not depend on “pathognomonic” signs and symptoms that define specific diseases. The algorithmic approach of the DSM system has been rightly popular: It uses “polythetic” criteria—making a list and then requiring a given number to be present. These quantitative thresholds are superior to asking clinicians to determine whether the patient’s condition resembles a prototype. But if a typical DSM diagnosis requires, for example, five out of nine criteria, nobody knows whether four or six criteria would have been more or less valid. Few categories have absolute requirements for any criterion, and no system of weighting takes into account the most characteristic features. The DSM system has been jocularly called a “Chinese menu” approach to diagnosis. But most clinicians need to consult the menu, and they would be hard put to remember all criteria for any category. Dimensionalization: The editors of DSM-5 thought that the solution to the comorbidity problem is to view disorders as dimensions—spectra of pathology that can be scored in terms of severity. All previous editions have classified mental disorders as specific categories, much like general medicine. One of the main ideas behind DSM-III was the revival of a model based on the work of the German psychiatrist Emil Kraepelin (1856–1926). Categories are consistent with the view that psychiatry concerns itself with mental illness, not with unhappiness or life itself. They also imply that psychopathology falls into a set of categories or natural kinds, much like tuberculosis or most forms of cancer. DSM-5 sought to overthrow this “neo-Kraepelinian” approach and replace it with a model in which normality and illness lie on a continuum. The rationale is that research suggests the underlying biology of mental disorders is more dimensional than categorical. But measuring the EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 10 | Part I Diagn ostic P ri n cip l e s severity of depression is not like taking blood pressure. The definition of dimensions is based on observation rather than biological markers, and it can only be provisional. Dimensional diagnosis also runs the risk of being overinclusive. Even normal people have some symptoms of disorder but do not deserve a formal diagnosis. Because differences in degree can become differences in kind, categories are necessary. Expert Consensus: DSM-5 is not a scientific document but, rather, a product of consensus by committees of experts. Sometimes the outcome depends on who was put on these committees. Where experts disagree, there is a way to “fix” results in advance—by ensuring that membership reflects a preexisting point of view. There are many scientific disputes affecting diagnosis, but most reflect a lack of basic knowledge. As the American physician Alvan Feinstein once remarked, the consensus of experts is the source of most medical errors. In summary, DSM-5 was a noble attempt at a revision in line with current research, and it can be considered as a draft for future editions based on more data. What has to be kept in mind is that the new manual only begins to develop a better framework for research and practice. Psychiatry has to put off scientifically based definitions of mental disorders to a future time when it knows more. The Constituencies of DSM-5 A diagnostic manual serves many purposes and has many potential constituencies. Let us consider each of them. Clinical Practice: The most important consumers of a diagnostic manual are mental health clinicians: psychiatrists, psychologists, social workers, and family physicians. Practitioners use the manual on a daily basis but are strapped for time. Researchers do not mind if procedures for reaching a diagnosis are complicated, but clinicians do. If the manual is not user-friendly, it will never be used as intended—or not used at all. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 1 I n t ro d u c t i o n | 1 1 Clinicians do not have the time or the inclination to open a book and count criteria. (They are even less likely to score symptoms on rating scales.) That is why previous editions of DSM were never applied in a systematic way. Many (if not most) users of DSM-5 may prefer an electronic version that can be easily searched. Even so, given that previous printed editions have not been used as intended, it is unlikely that the text of DSM-5 will be regularly consulted, even when available on mobile devices. Clinicians need to reach conclusions rapidly. They rarely follow algorithmic procedures, and they prefer to make diagnoses intuitively. Most have a prototype in their mind as to what any disorder should look like. The more closely a patient fits this model, the more likely it is that a diagnosis will be made. In this light, DSM-5 will not make as much difference to real-world practice as one might imagine. Because the details of DSM-III and DSM-IV were complicated, clinicians were happy to leave systematic diagnosis to researchers. Previous editions of DSM were poor guides to therapy. To be fair, the system was never intended to guide treatment. (This principle was explicitly stated in DSM-III, but clinicians did not seem to believe it.) As mental health practice becomes increasingly evidence-based, it could eventually develop specific treatments for diagnoses based on research. Doing so is not possible now. Only a few well-established links are known between any diagnostic category and specific therapeutic options. Research: This is the area in which the DSM-5 manual will be followed most systematically. Diagnosis is an essential tool for clinical investigation, and researchers need to establish that their studies examine populations that correspond to accepted rules of classification. However, changing criteria for mental disorders leads to discontinuities, making it more difficult to compare older studies to newer ones. The question is whether changes in DSM-5 can move research forward or only create unnecessary confusion. Another issue is whether the more complex procedures described in DSM-5 should be reserved for researchers if they are the people most likely to apply these procedures. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 12 | Part I Diagn ostic P ri n cip l e s The Pharmaceutical Industry: This constituency has a strong interest in DSM-5. Companies are interested in maximizing their profits; one way to do so is to get physicians to prescribe more drugs for more people. Any change that encourages wider diagnosis of mental disorders as a whole is in their interest. Specifically, the way DSM defines schizophrenia, bipolar disorder, and major depression could have an impact on industry profits. Some of the most problematic trends in modern psychiatry have resulted from attempts to make patients fit into categories that justify the prescription of drugs. But overinclusiveness tends to make the pharmaceutical industry happy. The Legal System: Lawyers and judges are also interested in DSM-5. Psychiatric diagnoses have found their way into the court system, affecting everything from criminal responsibility to custody rights and insurance payments. Although the science behind diagnosis does not justify any of these practices, they are widespread. The General Public: Finally, DSM-5 has and will continue to influence the way everyone views mental illness. Patients (and nonpatients) have access to published criteria and sometimes diagnose themselves (or their relatives). This amplifies the danger that too many people will receive psychiatric diagnoses. The way consumers and families view mental problems will also have an influence on practice, most likely in the direction of more aggressive treatment. The one certain thing about DSM-5 was that it would be another best-seller. What is less certain is whether it would lead to improved mental health care. Ten Highlights of DSM-5 Although many changes in the new manual are relatively minor, I highlight areas in which major revisions have been made, particularly those that have aroused controversy. All will be discussed in detail in this book. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 1 I n t ro d u c t i o n | 1 3 1. DSM-5 is reorganized into a new set of chapters that either reflect common clinical features or fall within a spectrum. Because most mental disorders begin early in development, there is no separate section for disorders first apparent in childhood. 2. The multiaxial system introduced in DSM-III has been eliminated. There is now no such thing as five axes, and personality disorders are considered in the same way as other categories. 3. Functioning, previously coded on Axis V, is now rated by scores on an instrument developed by the World Health Organization. 4. The criteria for attention-deficit hyperactivity disorder in adults have been expanded somewhat (by changing the requirements for a childhood onset). 5. Personality disorders are defined in the same way as in DSM-IV, but an alternative system based on trait dimensions can be found in a separate section of the manual. 6. Substance use disorders now describe cases using the term addiction, no longer distinguishing between dependence and abuse. 7. Highly moody and aggressive children can be given a new diagnosis—disruptive mood regulation disorder with dysphoria. 8. Autism spectrum disorders consider classical autism and Asperger’s syndrome as being on the same spectrum. 9. Dementias are classified as neurocognitive disorders, rated by severity on a spectrum. 10. Somatic symptom disorders replace somatoform disorders and are classified differently. Some of the most controversial changes that were proposed earlier in the DSM-5 project were either dropped or greatly diluted. Thus, attenuated psychosis syndrome (which might have led clinicians to treat people who have mild symptoms but never develop schizophrenia) was moved to a section of conditions requiring further study. A proposal to reduce the length required for a hypomanic episode from 4 days to 1 or 2 days was not adopted. The potential EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 14 | Part I Diagn ostic P ri n cip l e s impact of dropping the grief exclusion in diagnosing depression was diluted—by warning clinicians to avoid making a diagnosis when the course of mourning appears relatively normal. The range of autism spectrum disorder has been kept limited. A radically different system for classifying personality disorders was not accepted. Although it is assumed that most mental disorders lie on a spectrum with normality and have subclinical forms, dimensionalization was not consistently applied. Formal severity ratings for diagnoses, too complex for clinical use, were considered to require further study. The Structure of This Book The first part of this book is devoted to broader issues. Chapter 2 reviews the history of psychiatric diagnosis, Chapter 3 how diagnostic manuals are prepared, Chapter 4 how diagnoses are validated, Chapter 5 how mental disorder can be separated from normality, and Chapter 6 how dimensional assessment could be used. Chapter 7 examines clinical utility. The second part examines the major diagnostic groups in DSM-5. Chapters 8–14 present separate discussions of the most frequently used diagnoses: psychoses, bipolar disorder, depressive disorders, anxiety disorders, obsessive–compulsive disorder, neurodevelopmental disorders, impulse control and conduct disorders, eating disorders, sexual disorders, and personality disorders. Chapter 15 takes a briefer look at neurocognitive disorders, somatic symptom disorders, dissociative disorders, sleep–wake disorders, elimination disorders, and adjustment disorders. In Part III, Chapter 16 examines responses to DSM-5 from the scientific and clinical communities, and it comments on an alternative system proposed by the National Institute of Mental Health. Chapter 17 discusses how clinicians can use the manual in practice. Chapter 18 examines the future of psychiatric diagnosis, suggesting guidelines for the practical use of DSM-5 in clinical work and underlining issues that need to be resolved for the next edition—DSM-6. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 2 The History of Diagnosis in Psychiatry Why Is Diagnosis Important? Since the dawn of medicine, diagnosis has been essential to practice. Physicians need to organize the chaos of clinical symptoms into meaningful categories of disease. They also need to make a diagnosis before prescribing treatment. Ideally, valid medical diagnoses should be rooted in an understanding of disease processes. They should be based on a specific cause (etiology) and on a specific pathway to illness (pathogenesis). Yet many categories in medicine have been little but descriptions of signs and symptoms. Patients come to clinical attention with physical changes (signs) and subjective complaints (symptoms). But these are only the apparent manifestations of pathology. The great advances of medicine over the course of the nineteenth and twentieth centuries depended on understanding underlying mechanisms. Some of the most important discoveries showed that apparent symptoms (pain, fever, swelling, anemia, and jaundice) can be due to entirely different pathological processes. Differential diagnosis is a “game” that every medical student is expected to learn how to play. Every set of symptoms, even the most common, can be explained by a variety of causes, and it is the job of the physician to sort these possibilities out. Differential diagnosis is much like detective work. Every detail of history, physical examination, and laboratory findings can be a clue. Sir Arthur Conan Doyle based the character of Sherlock Holmes on one of his medical school teachers, Joseph Bell (1837–1911), who gave his name to Bell’s palsy and could deduce a great deal from a small amount of information. 15 EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 16 | Part I Diagn ostic P ri n cip l e s The discovery of a difficult diagnosis is the subject of an even more complex game—the Clinical Pathological Conference (CPC). An expert is asked to review all the records of a difficult case, and the correct (but often missed) diagnosis is revealed by an autopsy. (It has been said that pathologists are always right, but they are usually too late.) These exercises have long been carried out at top medical schools, and a series has been published for several decades in the New England Journal of Medicine. The detective work of diagnosis has also become the subject of popular columns in newspapers and magazines. The reader is given a clinical presentation (often from an emergency room), and the process by which an astute physician reaches a correct diagnosis is described. The main difference from a CPC is that the outcome is a good news story. Despite the importance of diagnosis, physicians still spend much of their efforts treating symptoms. The great Canadian physician William Osler (1898) opposed the “shotgun” medicine of his time, in which every symptom was managed with a different drug. (As we will see, despite advances in medical science, that practice remains common, especially in psychiatry.) But psychiatry is not the only specialty in which etiology and pathogenesis are unknown. In some areas of medicine (e.g., infectious diseases), valid diagnoses can be based on an understanding of underlying pathological processes. In others (most chronic diseases), that is not possible. Yet even when knowledge of disease is limited, diagnosis performs a number of important functions. First and foremost, it allows physicians to communicate with each other. When one informs a colleague that a patient has a classical case of peptic ulcer—or paranoid schizophrenia—a vast amount of information is conveyed by a single diagnostic term. Second, diagnosis offers something important to patients: a validation that they are indeed sick, an explanation for why, as well as what can be done for them and a prognosis. Even when prospects for effective treatment are slim, most people feel better when they receive a diagnosis. At the very minimum, suffering is no longer a mystery, and one can expect to benefit from whatever knowledge medical science has at hand. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 2 T he H i s tory of D i a gno si s i n P sy c h i a t r y | 1 7 Third, diagnosis provides researchers with a tool for conducting investigations and for developing theoretical models of disease. That is why cancer research uses coding of disease types and staging and why clinical research in psychiatry makes use of standardized interviews. Fourth, diagnosis helps physicians to plan treatment and to establish a prognosis. When research is available to determine outcome, planning can be more rational. Fifth, diagnosis aims to provide categories specific enough to guide the choice of treatment. Currently, only a few treatments, such as antibiotics, can claim that kind of specificity, and even then, drugs are often prescribed without a clear idea as to what is wrong with the patient. Yet medicine is slowly but inexorably moving in the direction of specificity. Pharmacogenetics may be in its infancy, but it is already being applied to a few diseases. In the future, psychiatry might benefit from this approach. Diseases, Disorders, and Syndromes Valid medical diagnosis is a relatively recent phenomenon, but it is based on more than a century of research (Balint et al., 2006). Over most of the history of medicine, illnesses could be described only as syndromes (a cluster of commonly associated signs and symptoms). These syndromes could have a multiplicity of causes. For example, the popular eighteenth-century category of “dropsy” (swelling of the extremities) confused edema due to heart disease, kidney disease, and a variety of other causes. In the nineteenth century, only a few true illnesses could be properly diagnosed (mainly infectious diseases). Even so, causes were not well understood before the advent of the germ theory of disease in the 1880s, and it took many years before that theory resulted in effective treatment for infections. The late nineteenth century was a time of rapid progress in medical research. The work of chemists such as Louis Pasteur (1822–1895) and bacteriologists such as Robert Koch (1843–1910) led to the identification of specific infectious agents behind many diseases. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 18 | Part I Diagn ostic P ri n cip l e s The work of pathologists such as Rudolph Virchow (1821–1902) allowed scientists to directly observe disease processes at the level of the organ and of the cell. Despite these advances, physicians were not yet able to help most of their patients. By the early twentieth century, scientific medicine entered a period of ascendancy. William Osler (1849–1919) was one of the key figures. Over several decades, working at four universities (McGill, Pennsylvania, Johns Hopkins, and Cambridge), he established many of the principles that still guide medical education and practice (Osler, 1898). These include diagnosis based on detailed observation of signs, careful listening to patients’ symptoms, and laboratory tests to confirm the presence of a pathological process. As long as physicians were limited in their ability to treat disease, diagnosis did not necessarily lead to specific and effective therapy. But later in the twentieth century, medical therapeutics greatly advanced. The introduction of sulfa drugs in the 1930s and of antibiotics such as penicillin after World War II was followed by a cornucopia of effective agents for many other conditions. Now accurate diagnosis really began to make a difference. Again, the most dramatic example was infectious diseases, where lives could be saved by culturing a specific microorganism and by prescribing an antibiotic to which it was sensitive. Later, similar principles were applied to other diseases. To treat syndromes such as anemia, hypertension, and congestive heart failure, physicians need to divide them into diagnostic categories based on specific pathological mechanisms. Even in psychiatry, where mechanisms are rarely understood, bipolar disorders can be separated (at least partially) from other conditions by a relatively specific response to mood stabilizers (Goodwin & Jamison, 2007). Principles of Nosology “Nosology” refers to the science of diagnosis (Black et al., 2014). This term gives the impression that diagnostic categories are scientific and based on empirical data. Yet all too often they are not. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 2 T he H i s tory of D i a gno si s i n P sy c h i a t r y | 1 9 Although the problem is more severe in psychiatry, uncertainty affects many medical diagnoses. Categories can change as knowledge increases. For example, when I was a medical student, we studied a disease called “viral hepatitis.” That entity has now been subdivided into hepatitis A, hepatitis B, hepatitis C, and hepatitis D—with more to come in the future as separate infectious agents, each with a unique method of transmission, are identified. One can imagine the same process occurring in other poorly understood diseases, each of which could arise from a different pathological process. Medicine need not worry about validity for diagnoses that are based on known etiology and pathogenesis. It can also support many categories using medical imaging, biological markers, and cellular processes. Ideally, diagnosis evolves lockstep with research. Even so, many—if not most—diseases remain mysterious. That is particularly the case when it comes to mental disorders. To be fair, medicine and psychiatry are not the only areas of science in which classification can be problematic. Biology offers an illustrative example. There are more than 1 million types of multicellular organisms, and the number of single-celled species is much larger. The taxonomy developed by the Swedish scientist Carl Linnaeus (1707–1778) was a breakthrough in its time and is still used. But as with diagnosis in medicine, classical taxonomy is based almost entirely on appearances. Although biologists have had no trouble understanding that birds and bats belong to different groups, subtler distinctions have not always been clear. The classification of organisms can be based on evolutionary relationships, but the tools to carry out such analyses have only been available relatively recently, as the use of DNA as a marker became practical. Using this tool allowed “the tree of life” to be organized into three domains (Sapp, 2009; Archaea, Bacteria, and Eukarya) divided into six kingdoms (Archaebacteria, Eubacteria, Protista, Fungi, Plantae, and Animalia). Even so, there are boundary problems—for example, the question of whether or not viruses are living organisms. Nuclear physics offers another example (Schumm, 2004). Matters were relatively simple when the only known particles were EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 20 | Part I Diagn ostic P ri n cip l e s electrons, protons, and neutrons. As dozens of other “elementary particles” were discovered, physics faced a crisis. The development of quark theory resolved the problem by describing all these phenomena as combinations of much smaller entities—which seem, at least for now, to be irreducible. Even so, this classification (as well as the actual existence of some of the particles predicted by the theory) remains controversial. Although some of these problems may be resolved by experiments conducted in the Large Hadron Collider, physics, like psychiatry, sometimes has to use a classification system with uncertain boundaries. If the “hard sciences” face difficulties of the same kind, physicians and mental health professionals should feel a little better about their own problems in classification. Why Psychiatric Diagnosis Is Difficult The categories used in psychiatric diagnosis are based on observation of signs and symptoms rather than on pathological processes. One can make use of a few signs, such as facial expressions associated with depression, or the flight of ideas associated with mania. But what clinicians mainly use for diagnosis are symptoms, the subjective experiences reported by patients. Psychiatrists have little knowledge of the processes that lie behind these phenomena. Thus, psychiatric diagnoses, with very few exceptions, are syndromes, not diseases. Many have hoped that advances in neuroscience would solve these problems. After all, changes in thought, emotion, and behavior must ultimately reflect neural processes. Disorders of the mind are also disorders of the brain. But the brain is not as easy to understand as the heart or the kidney. It may be the most complex structure in the entire universe. Thus, mental disorders cannot easily be reduced to the biology of neurons. With billions of neurons, billions more glia, and trillions of synapses connecting neurons to each other, the brain does not lend itself to any simple explanation. To add to the complexity, psychological phenomena are shaped by life EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 2 T he H i s tory of D i a gno si s i n P sy c h i a t r y | 2 1 experiences and by a sociocultural milieu. It is not surprising that mental illness is so difficult to understand. Moreover, although mind depends on the brain, mind cannot be entirely reduced to the activity of neurons. Mental processes are “emergent” phenomena that cannot be explained on the level of cellular activity or synapses (Gold, 2009). They require another level of analysis, in which thoughts, feelings, and behaviors are studied in and of themselves. In summary, although research has provided some insight into the localization and mechanism of brain function, psychiatry today stands about where the rest of medicine was 100 years ago. It will take many decades to answer even the most basic questions facing neuroscience. It was an illusion to believe that we knew enough in 2013 to create a classification of mental illness based on biology. The DSM System The International Classification of Diseases (ICD), a system sponsored by the World Health Organization (WHO), is the most widely recognized classification of medical illness. Even today, DSM codes are “translated” for ICD, the official system worldwide. Originally derived from a list of causes of death, the first version of ICD was compiled in 1893. Mental disorders were first listed in ICD-6, published in 1949. Although mental illnesses took time to be recognized, the WHO system has become more sophisticated with each revision; the current version, ICD-10 (World Health Organization, 1993), differs from DSM-IV only in detail. ICD-11 is planned to appear in 2017 and to be more or less compatible with DSM-5. (It remains unclear to what extent that will be the case.) ICD has been eclipsed throughout the world by the more detailed and systematic American system—the Diagnostic and Statistical Manual of Mental Disorders. A preference for DSM reflects the dominance of research in the United States and the wish of clinicians and investigators to use categories compatible with American science EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 22 | Part I Diagn ostic P ri n cip l e s that are used in most medical and psychological journals. However, there is a more substantive reason for the greater influence of DSM. That is due to the manual being algorithmic so that clinicians count observed criteria and then follow an established logical sequence. This approach is, in principle, more amenable to science. It is also much easier to count criteria than to match detailed descriptions. Instead, ICD describes prototypes for each of its categories, which the clinician is asked to determine if a case approximates. This algorithmic approach to diagnosis dates from the publication of DSM-III in 1980. In 1952, the American Psychiatric Association published DSM-1, which was mainly intended to keep statistical records and was not much of a scientific instrument. I learned DSM-I as a medical student: The manual was thin, with 130 pages describing 106 disorders. It had nowhere near the impact of later editions. The most important limitation of DSM-I was that it listed disorders, described them briefly, but did not precisely define them. Without algorithms for diagnosis, reliability was inevitably low. As a result, psychiatrists could not even agree on their most basic diagnostic concepts. For example, American psychiatrists of 50 years ago had an overly broad concept of schizophrenia and were not in accord with their British colleagues, who were more likely to diagnose psychotic patients as having manic–depressive illness. The problem was documented by research in which videotapes of interviews were shown to psychiatrists on both sides of the Atlantic Ocean (Cooper et al., 1972). Later, American clinicians came to diagnose patients in much the same way as their British cousins. A second problem with DSM-I was that it adhered to theoretical models that were eventually found wanting. Under the influence of the Swiss–American psychiatrist Adolf Meyer (1866–1950), who favored environmental models of etiology, almost all mental illnesses were described as “reactions.” (There was even a category called “schizophrenic reaction.”) Such turns of phrase implied that all mental disorders are reactions to environmental stressors. Although this idea contains a grain of truth, the concept is misleading. It entirely misses the essence of disease processes, which have a trajectory of their own, even when environmental factors act as EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 2 T he H i s tory of D i a gno si s i n P sy c h i a t r y | 2 3 precipitants. In internal medicine, stressors—both physical and psychological—can raise blood pressure, but no one would consider making a diagnosis of “hypertensive reaction.” DSM-I also reflected the strong influence of psychoanalytic theory. At that time, many of the leaders of American psychiatry were either trained analysts or sympathetic to the analytic movement. Several disorders (mild depression, anxiety, conversions, phobias, and obsessive–compulsive symptoms) were classified as “neuroses”—a term popularized by Freud. The manual specifically stated that such symptoms were the result of “unconscious conflict.” How one might assess the presence of such a process was left to the clinician. Clearly, the era of basing diagnosis on measurable phenomena had not yet arrived. In the end, DSM-I was used for hospital records, but it never had a defining role in research or practice. It was also not consistent with the ICD system, isolating American psychiatry from the rest of the world. DSM-II, introduced in 1968, was taught to me when I was a psychiatric resident. Its 134 pages described 182 disorders. All these diagnoses were supposed to be compatible with ICD. The term “reaction” disappeared entirely—schizophrenia was now just “schizophrenia.” However, the psychoanalytic influence on the definition of disease remained in place. Neuroses were still described as due to unconscious conflict, as every good Freudian believed. Also, because the definitions of each category were not algorithmic, the reliability problem was in no way resolved. Although all psychiatric residents had to learn DSM-II, we did not take it very seriously. For one thing, it was written in descriptive paragraphs rather than algorithmic criteria. Thus, there was too much latitude for clinicians to interpret phenomena in their own way, with the result that DSM-II diagnoses were not particularly reliable. But at the time, diagnosis had few implications for treatment. Psychotic patients were given antipsychotics, whereas antidepressants were prescribed for depression. Everyone else got psychotherapy, and diagnosis did not make that much difference in choosing how to conduct it. The classification of mental disorders only became a hot topic when DSM-III was published. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 24 | Part I Diagn ostic P ri n cip l e s The DSM-III Revolution In 1974, only 6 years after the publication of DSM-II, the American Psychiatric Association (APA) realized that the problems of diagnosis in psychiatry were too severe to retain the second edition. This was an era in which critics who refused to believe in the reality of mental illness were vigorously attacking psychiatry. Many had a political agenda. On the right, the American psychiatrist Thomas Szasz (1961) was a libertarian who did not want to allow any role for the state in determining personal conduct and rejected psychiatric diagnosis because it can be used to support the involuntary commitment of psychotic patients. On the left, the British psychoanalyst Ronald Laing (1967) claimed that mental illness is a response to an insane society—a point of view that fit the spirit of the 1960s. Laing was against diagnosis for the same reason he was against medication—he believed that psychosis could be a personal journey that only required an expert guide. Obviously, such critiques were well out of the mainstream of medical thought. Yet they had a wide popular appeal at the time, and psychiatry felt the pressure. Moreover, if, as research showed, diagnosis was not reliable, no one could trust it. It was important for the field to show that the classification of mental disorders had some basis in science. Perhaps the most important factor in the APA’s decision to revise DSM was psychiatry’s need to overcome its isolation from the rest of medicine (Spitzer, 1991). DSM-II was based on unproven theories and had categories that looked nothing like medical diagnoses. Thus, psychiatrists earned little respect from their colleagues. Of course, inaccurate diagnosis is not the only reason why physicians disrespected psychiatry. The stigma associated with mental illness was, and remains, the most important factor (Corrigan, 2005). But the blatantly unscientific system used in DSM-II did not help. In the course of the 1970s, the APA—under the leadership of its director, Melvin Sabshin (1902–1987)—began to prepare the next edition of DSM. The APA chose Robert Spitzer (1932–), a professor EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 2 T he H i s tory of D i a gno si s i n P sy c h i a t r y | 2 5 from Columbia University, to lead the task force. This was a time of change and ferment in psychiatry, and the selection of Spitzer proved pivotal. A former analyst who had rejected Freud, Spitzer focused his career on developing better methods of assessment for mental illness. Spitzer’s concept for the new edition was based on the research of a group of psychiatrists at Washington University in St. Louis, led by Eli Robins (1922–1995) and Samuel Guze (1924–2000). These men began as renegades but became the leaders of a new psychiatry. Dismissing psychoanalysis out of hand, they wanted to move American psychiatry into consonance with traditions developed in Europe. Spitzer was a natural ally for the Washington University group, several of whom he brought into his DSM task force. Like many of his contemporaries in academic psychiatry, Spitzer was disillusioned with older paradigms and looking for something different. His interest in psychometrics was based on the principle that diagnosis, as well as signs and symptoms on which categories are based, can be quantified. Spitzer was following a long-standing principle in science: The only valid concepts are those that can be measured with numbers. This point of view involved a return to principles developed by the German professor Emil Kraepelin (1856–1926). Kraepelin, a contemporary of Freud, was the leading psychiatrist on the European continent in the early twentieth century and became famous for his separation of psychoses into schizophrenia and manic depression (Kraepelin, 1921). As Shorter (1997) observed, Kraepelin turned out to be much more important for contemporary psychiatry than Freud, whose star has rapidly faded. That is why DSM-III was described as “neo-Kraepelinian” (Klerman, 1986). Kraepelin understood that psychiatric diagnosis must eventually be based on biological processes. But while waiting for specific markers to be discovered, categories can be provisionally based on signs and symptoms, as well as on clinical course, prognosis, and treatment response. That was precisely the view of Spitzer and of the group at Washington University. One of the assumptions of Kraepelinian psychiatry was that categories of disease are real, even if they remain to be discovered. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 26 | Part I Diagn ostic P ri n cip l e s This view is in accord with the approach of modern medicine. Yet some view it as a form of “essentialism” that fails to acknowledge that diagnostic categories inevitably have fuzzy edges (Livesley, 2011a). DSM-5 seeks to go beyond Kraepelin, accepting categories as a temporary expedient but viewing illness as a point on a broad continuum that shades into normality. Whether or not this paradigm ultimately prevails, in the absence of biological markers for disease, DSM-III and its successors were not in a position to reach Kraepelin’s goals. But the neo-Kraepelinians rightly insisted on observable, phenomenological criteria. One of the main effects of this principle was to undermine the influence of psychoanalysis on American psychiatry (Paris, 2005, 2008a) and to replace that paradigm with a new perspective. Some years earlier, Robins and Guze (1970) had developed a set of criteria that could be used to define schizophrenia and other major psychiatric disorders. The system focused on observable phenomena and was algorithmic (i.e., it had a defined pathway from observation to diagnosis). This approach, often called the “Feighner criteria” after the lead author of the seminal paper (Feighner et al., 1972), was the germ of DSM-III. It was the model on which all diagnosis in the third edition was built (Kendler et al., 2010;). The Washington University group also proposed that these “research diagnostic criteria” could be used as a general benchmark for diagnostic validity (Robins & Guze, 1970). Their idea was that all diagnoses should be based on (1) precise clinical description, (2) laboratory studies identifying biological markers, (3) clear delineation from other disorders, (4) a characteristic outcome in follow-up studies, and (5) a genetic pattern in family history studies. Although none of these criteria were directly based on etiology or pathogenesis, they could be markers for disease processes. The Robins–Guze criteria were similar to the way medical diagnoses are validated. But these goals, however modest, have proven to be beyond reach. Twenty years later, no major mental disorder had met this benchmark (Blashfield & Livesley, 1999), and the situation has not changed. Moreover, some of these assumptions have been challenged (Hyman, 2007). Mental disorders, if they do not correspond EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 2 T he H i s tory of D i a gno si s i n P sy c h i a t r y | 2 7 to strict categories, may not have the characteristic features suggested by such a paradigm. The Impact of DSM-III DSM-III was much larger than any previous edition: 494 pages describing 265 categories. It was a true paradigm shift that threatened some, drew applause from others, and aroused great controversy. It may be difficult for a new generation, brought up on this system, to understand the tumult that preceded and followed its adoption. In particular, most psychoanalysts opposed DSM-III. They rightly perceived that it contradicted their worldview and loosened their hold on the profession. Some thought the manual would destroy psychiatry. For example, early drafts of DSM eliminated the concept of neurosis entirely and made no mention whatsoever of an unconscious. For a while, angry psychoanalysts threatened to secede from APA as a group. Then, in a clever move, Spitzer fashioned a compromise in which the term “neurosis” continued to appear, but only in parentheses. (That term was dropped entirely in DSM-III-R.) Another source of resistance was that DSM-III took, at least at first, an unfamiliar approach. Diagnosis had long been considered an art, based on clinical experience. Now, with specified criteria, anyone could do it. If you could assess signs and symptoms, you just had to open the book and count. Making diagnosis easy demystified psychiatry in that its procedures could be used by family doctors and by nonmedical professionals. Some thought DSM diagnosis was too robotic, but this conclusion was mistaken. A final diagnosis may depend on an algorithm, but it takes a fair amount of experience to assess whether criteria are present or whether they are clinically significant. In the end, the momentum of DSM-III proved unstoppable. Psychiatrists were no longer willing to stand outside of medicine and be mocked and looked down on by their colleagues. Even if they could not aspire to having a specialty fully grounded in empirical data, they now had a diagnostic system that at least looked scientific. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 28 | Part I Diagn ostic P ri n cip l e s DSM-III met a need, and almost everyone began to use it. Today, hardly anyone can remember being against it. One of the main criticisms of psychiatric diagnosis had been that clinicians seeing the same patient might not make the same diagnosis. The absence of reliability was a potentially fatal problem. As every psychology student knows, measurements cannot be valid without first being reliable. Low reliability ultimately reflected the fact that the criteria sets of earlier DSM manuals were vague. If one uses a “prototype”—that is, a description of a typical clinical presentation—one expects the clinician to determine whether a patient’s signs and symptoms approximate a written description (Berganza et al., 2005). But doing so is not easy, and different raters may still come to different conclusions. That remains the main weakness of the ICD system. Even if you do not have the data to determine diagnostic validity, you can prioritize reliability. That is precisely what DSM-III did. The problem is that we can all agree—and all be wrong. Even so, it was better to have categories that everyone can agree on. Diagnostic validity would just have to wait. Interestingly, although some psychiatrists resisted DSM-III, clinical psychologists were generally positive. That was quite an achievement, given the traditional competitiveness between these two professions. What psychologists liked about the system was that it looked like the criteria they learned in graduate school and used for many other purposes: relatively precise definitions, with algorithms leading to a conclusion. In this respect, DSM-III diverged significantly from ICD. That is why DSM took precedence—not only in the United States but also throughout the world. It is now difficult to find a scientific paper that does not use the DSM system or to find a group of clinicians for whom the manual is entirely unfamiliar. The DSM System Since 1980 The year 1980 was a watershed. The DSM system changed relatively little during the next 30 years. It took time for practitioners to EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 2 T he H i s tory of D i a gno si s i n P sy c h i a t r y | 2 9 adapt to a radically new method of classification. Moreover, further changes in diagnosis could be problematic for researchers. If it was standard for all patient samples to be described according to DSM, then changing the criteria could put a research paper out of date even before it was published. Moreover, there was some tinkering in DSM-III-R (APA, 1987). The manual was now 567 pages long and described 292 diagnoses. The most significant shift was that hierarchical rules (excluding a diagnosis if another category explains the same clinical features) were greatly restricted. That led to an even greater degree of “comorbidity” (multiple diagnoses)—a problem that, as we will see, remains unresolved. Some psychiatrists believed that the changes in DSM-III-R were not sufficient to justify a new manual. Murmurings were heard that revisions were arbitrary and that they came out of informal meetings in Spitzer’s basement. Suspicions were even raised about the large profits that APA made every time a revision is published. After revolution, people crave stability. The APA eventually decided that stability in diagnosis was more important than Robert Spitzer. To this end, it assigned a different leader—Allen Frances (1942–), then a professor at Cornell University—to lead the DSM-IV process. This revision (APA, 1994) made fewer changes than DSM-III-R had made. It described 297 disorders in much greater detail (the length was now 886 pages). The most major innovation was a new section on sleep disorders. Another was the publication of “source books,” summaries of the research findings on which the manual was based. At the time, Frances stated that the new manual should be good for another 15 years. He was more than right—it lasted for 19 years. Only a few minor changes were introduced in a “text revision,” DSM-IV-TR (APA, 2000), which did not change the criteria for disorders but discussed them slightly more thoroughly. Plans for a major revision began soon after DSM-IV-TR was published. The authors of the new edition viewed it as an opportunity to base the classification more firmly on neuroscience (Kupfer et al., 2002; Regier et al., 2009). This book will offer a critical examination of whether that goal has been reached. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 30 | Part I Diagn ostic P ri n cip l e s Because research continues to make slow progress, we do not know how many years it will take for the next major revision to be prepared. The question is whether it is better to maintain stability or to introduce a system that allows for continuous update. The reason why DSM-5 uses an Arabic (rather than a Roman) numeral is that it is open to revisions, even prior to DSM-6. Like computer programs that are updated on the Internet, a DSM-5.1 or -5.2 could appear. The upside is that if a great discovery is made, it can be included. Also, it may be easier for clinicians to accept change gradually. The downside is that changing criteria can be disruptive for both research and practice. How the DSM System Shaped Psychiatry Every mental health clinician needs a copy of DSM-5 (or at least the list of criteria in an inexpensive paperback edition)—even if they do not read it cover to cover. And the way that patients are classified can have an effect on the treatment they receive—even though diagnosis need not determine therapy. Every research project in the coming years will have to take the new system into account. In 947 pages, it lists more diagnoses in total (541) than DSM-IV, although because some are subtypes of broader categories, the number with specific criteria is actually less. In any case, all diagnostic instruments based on DSM-III or DSM-IV will have to be revised. Within a few years, all medical journals receiving submissions about clinical populations will require a DSM-5 diagnosis. The residents I teach all want to know if they have to master the new system to pass their exams. Mental health professionals also need to use DSM-5 to write reports on their patients. Textbooks of psychiatry have been built around DSM diagnoses for the past 35 years. Even doubtful categories are given their own chapter—forcing editors to choose proponents of the most controversial diagnoses as authors. This implicit validation is one of the reasons why it has been so difficult to remove any diagnoses from the manual. Moreover, the bar for removal is as high as the bar for EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 2 T he H i s tory of D i a gno si s i n P sy c h i a t r y | 3 1 inclusion. (Even in a hard science such as astronomy, the demotion of Pluto to a “dwarf planet” in 2006 drew loud protests.) There was a time when psychiatrists were known as deep thinkers, not classifiers of disease. All that changed in 1980. Today, the field of psychiatry has come to be organized around the DSM system. It may not be, as the media sometimes claim, “psychiatry’s bible.” But given the general public’s interest in psychiatry, each revision has been front-page news. Diagnosis and Treatment DSM-III included a disclaimer that diagnoses based on the manual should not necessarily lead to any specific mode of treatment. This remains the case for DSM-5, but it has been impossible to resist the linkage. Psychiatrists, as well as other physicians and clinical psychologists, are usually not interested in classification for the sake of classification. When they have a hammer, they search for nails. This can make them try to fit a patient into a category they think they know how to treat. Although today the hammer is usually a drug, diagnosis can also fit methods of psychotherapy, as shown by the vast interest in posttraumatic stress disorder. The pharmaceutical industry has not been shy to take advantage of these forces to encourage the use of more diagnoses. When they market a new drug, they often need to create a market for it. (These campaigns usually go under the rubric of providing “information” for practitioners.) For example, attention-deficit hyperactivity disorder is diagnosed much more often now, in adults as well as in children, in part because of pharmaceutical promotion for new agents (to replace the tried-and-true option of methylphenidate). Similarly, one reason why major depression tends to be diagnosed is the large number of antidepressants on the market. Also, bipolar disorder tends to be diagnosed because of the perceived effectiveness of mood stabilizers and antipsychotics. In contrast, a relative lack of interest in anxiety disorders reflects the absence of newer and more effective pharmaceutical options. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 32 | Part I Diagn ostic P ri n cip l e s There are exceptions to this principle. For example, there has been an increase in the diagnosis of autism and autistic spectrum disorders despite weak evidence for the efficacy of therapy. Here, the driving force seems to have been fascination with the diagnostic construct. The claim that DSM-5 represents the latest in scientific knowledge is doubtful. Diagnosis is not necessarily a neutral and empirically based procedure. It is driven by a variety of social forces lying outside of medicine (Horwitz, 2002). It can be influenced by academics promoting a theory or a favorite diagnosis. It can be influenced by practitioners’ desire for predictable clinical results. It can be influenced by patient advocacy—most of the main diagnoses in psychiatry now have their lobby group. It can also be influenced by the media, which have the power to affect everyone’s opinion—even experts. The authors of the DSM-5 may not acknowledge, or even be fully aware of, all these influences. That does not make them any less important. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 3 How Diagnostic Manuals Are Made Producing a diagnostic manual is a complex process that resembles a military operation. It requires a “general” and a hierarchy of command. The American Psychiatric Association (APA) has put the creation of each new manual in the hands of a “task force” chaired by a prominent academician. For DSM-III and DSM-III-R, that person was Robert Spitzer. For DSM-IV, it was Allen Frances. For DSM-5, the role was shared between two research psychiatrists: David Kupfer and Darrel Regier. Kupfer and Regier are prominent leaders in their fields. Kupfer is a mood disorder researcher who served for 26 years as Chair of Psychiatry at the University of Pittsburgh. Regier is an epidemiologist, a research administrator at the National Institute of Mental Health, and director of the APA’s Division of Research. Their point of view on diagnosis is rooted in extensive academic and research experience. But their clinical perspective is less clear. High-ranking academics do not see a large number of patients—most live in a rarified world that is protected from raw clinical reality. That is also true of most of the psychiatrists and social scientists working on DSM-5 committees. The experts involved in the process tend therefore to be influenced more by theory than by practice. The result is a manual designed to make researchers happy. Investigators have the luxury of taking all the time they need. They do not have to make diagnoses rapidly while multitasking—as many clinicians must. Insensitivity to the needs of busy practitioners tends to make the manual unwieldy for practice. DSM-5 has worked hard to inject more “science” into psychiatric classification, but the result may be more useful for researchers than for practitioners. 33 EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 34 | Part I Diagn ostic P ri n cip l e s The detailed writing of a DSM manual depends on many people. APA set up a group of task force members, most of whom were either chairs of “workgroups” (each of which dealt with a major group of disorders) or of “study groups” (each of which was asked to examine broader conceptual issues). All groups were composed of prominent researchers, and being a member was considered a great honor. The chairs were asked to choose the experts they wanted, and these decisions may have led to predetermined outcomes. The task force consisted of 28 people. Each of the workgroups had 6–12 members and conducted regular meetings, either in person or electronically. (Using e-mail, they had to travel only a couple of times a year to meet face to face.) Their mandate was to review the existing literature, prepare new sets of criteria, and field test them. They were assigned to examine the following groups of disorders: attention-deficit hyperactivity disorder (ADHD), anxiety, childhood and adolescence, eating, mood, neurocognitive, neurodevelopmental, personality, psychosis, sexual, sleep, somatic, and substance use. The study groups were assigned broader questions. One focused on spectra that cross diagnostic boundaries, recommendations for structuring categories, and developing better overall criteria for psychiatric diagnosis. A second was assigned to examine how developmental processes influence diagnosis. A third studied the influence of gender and culture. A fourth examined interfaces between psychiatry and medicine, with a mandate to develop a new definition of disability (to replace Axis V, the scoring system introduced in DSM-III). A fifth was assigned the task of reviewing the measurement of dimensions within categorical diagnoses. DSM-5 conducted a series of field trials in 2011 to determine whether the system was reliable and user-friendly. This was intended to allow for fine-tuning. However, the field trials suffered from a serious lack of time (Jones, 2012). Also, given the lack of comparisons with DSM-IV, it was difficult to determine whether the new system actually works better in practice. There was considerable debate in the literature about the wisdom and validity of making radical changes in DSM-5. However, it EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 3 H ow D i a gnos ti c M a n u a l s A re M a d e | 3 5 was decided to begin with a new team, excluding most of the experts who worked on DSM-IV. Although the editors backed away from their initial hope of a “paradigm shift,” workgroups were encouraged to be innovative. However, all decisions received scientific review by a separate committee led by an eminent academic psychiatrist, Kenneth Kendler of Virginia Commonwealth University. At the end of this complex process, all reports were submitted to the task force for approval. The final document of DSM-5 then had to be approved by the APA Board of Trustees and by an assembly of APA delegates from across the United States. Keeping Industry Out When DSM-III and DSM-IV were published, some critics expressed concern that the text had been subject to undue influence by the pharmaceutical industry (Kutchins & Kirk, 1997). Actually, drug companies had no direct input into the DSM process. But industry benefits financially from diagnoses that lead to a wider use of products that can obtain indications from the U.S. Food and Drug Administration. Also, experts in psychiatry, many of whom receive money from industry, can be biased in favor of expanding diagnostic categories. No one claims that industry can tell organized psychiatry how to write its diagnostic manual. But when so many of its key opinion leaders are in the pay of industry, diagnoses that lead to specific pharmaceutical indications could be more likely to get into DSM. That possibility is worrying. Thus, experts who take money from drug companies are likely to be biased, often without realizing that they are being so. They live in a climate of opinion that consistently favors new diagnoses and new drugs. That was a good reason to keep them out of the process of preparing DSM-5. But it was not possible to exclude everyone because almost every professor of psychiatry has been supported in some way by industry. Cosgrove and Krimsky (2012) have documented how the rules were stretched in a way that reduced, but in no way eliminated, conflict of interest. The best one can say is that EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 36 | Part I Diagn ostic P ri n cip l e s those who served took less money. Most of them will probably go back to industry for further support once the process is over. The APA has had a history of overly close relations with “Big Pharma.” Until recently, industry sponsored many events at its annual meeting, creating profits used to support the organization as a whole. This supported the suspicion that drug companies could somehow shape DSM-5. Actually, most industry funding is not used to support research but, rather, pays for pharmaceutical representatives and offers payment to experts who promote sales. Academics in the pay of Big Pharma often give talks that directly or indirectly support new drugs. They may also be paid to be “consultants” for industry or serve on “advisory boards,” which usually involves little real work but allows for attendance at conferences in interesting or exotic locales. The funds that professors of psychiatry take from pharmaceutical companies have made a few of them into millionaires. The latest drugs, few of which are very different from agents already on the market, are strongly promoted by these opinion leaders, who get paid for giving talks advising clinicians to use them. In short, it is possible for academic psychiatrists to be “bought” by the pharmaceutical industry (Healy & Thase, 2003). Even one of the chairs of DSM-5, David Kupfer, had provided services for several companies, although he stopped when he took on his position. In any case, there is little doubt that new diagnoses in psychiatry are good for business. For example, the relatively new category of social phobia generated billions in sales for the makers of antidepressants (Lane, 2007). The more categories there are in DSM-5, the better for industry. These concerns have led to a backlash against organized medicine for its overinvolvement with Big Pharma (Angell, 2000). Despite its weak position within medicine as a whole, psychiatrists take more money from industry than any other group of specialists. These conflicts of interest have the potential to corrupt both clinical practice and research. In 2008, Senator Charles Grassley of Iowa brought these issues to public attention. The spotlight was placed on academic psychiatrists who take millions of dollars from industry in “consultant fees” for promoting products in lecture tours. As EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 3 H ow D i a gnos ti c M a n u a l s A re M a d e | 3 7 reported in The New York Times (June 8, 2008), the chair of psychiatry at Emory University lost his job when these facts came out and when it became clear that he had not informed his university or the National Institute of Mental Health (NIMH) about how much money he had been paid. (Due to his fame and a close relationship to the leaders of NIMH, this psychiatrist had no trouble getting another chairmanship.) New guidelines governing the relationship between industry and professional organizations in medicine have been proposed to deal with these problems (Rothman et al., 2009). The DSM-5 process required that all task force and workgroup members be vetted and that only minimal involvement with pharmaceutical companies would be allowed from the time of participation. This rule slowed down the entire process (it took a full year to vet everyone). In the end, all task force members were declared to be “clean” of major involvement with industry. But if almost all of them have taken money from pharmaceutical companies in the past, one cannot be certain whether their objectivity was permanently compromised. Transparency Versus Secrecy The process of preparing DSM-5 was criticized for insufficient transparency (Frances, 2009a, 2009b, 2009c). A document with such an enormous influence on practice cannot be prepared in secret, and it needs to attain a degree of “buy-in” from potential users. Although all proposals for change were eventually put on a website for commentary, the initial process by which the new manual was revised was far from open. The authors of earlier editions had taken greater pains to consult widely. For years before the publication of DSM-III, I remember well-attended symposia at each annual meeting of APA in which all changes were discussed and feedback was considered seriously. (I even wrote Spitzer with a question and got a typed reply.) When DSM-IV was being prepared, drafts were sent for comments to experts who were not members of the workgroups. (I was one, even EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 38 | Part I Diagn ostic P ri n cip l e s if my comments had little effect on the outcome.) In contrast, the DSM-5 process was, at least at first, closed. This created suspicion that the task force wanted to avoid criticism and hoped to present psychiatry with a fait accompli. In a spirited exchange published in the newsletter Psychiatric Times, Allen Frances (2009a, 2009b), joined by Robert Spitzer (2009), criticized the confidentiality agreements signed by all workgroup members. Everyone had to promise to keep their discussions under wraps. This rule threatened to close the whole process to feedback. Both Frances and Spitzer also suggested that because many of the revisions under consideration were problematic, they needed to be openly and intensively debated outside the task force. A group representing DSM-5, led by a president of APA (Schatzberg et al., 2009), wrote back to deny these claims. The group argued that early drafts were too provisional to be up for general discussion and noted that the most major changes were being presented at a number of scientific meetings. Unfortunately, this letter included a nasty counteraccusation, raising serious questions about the judgment of those who wrote it. Schatzberg et al. claimed that the authors of previous editions (i.e., Frances and Spitzer) were motivated by a financial interest in books and assessment measures they published after DSM-III and DSM-IV. This comment made no sense because nobody would buy these books once DSM-5 was in place. Schatzberg himself had been accused of conflict of interest (by Senator Grassley) for promoting drugs in which he had a financial interest. The tone of his reply shows how badly APA was stung by criticism. The process of writing the manual should have been more open from the beginning. When you are making changes that may or may not be valid or user-friendly, you should circulate proposals widely and open them up to scientific debate. The bigger the decision, the more input from clinicians and researchers is needed. Although everyone eventually had the opportunity to submit suggestions on the Web, I doubt that they were taken seriously. In the end, all proposed changes were published on the DSM-5 website in February 2010. Further revisions were posted in 2011 EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 3 H ow D i a gnos ti c M a n u a l s A re M a d e | 3 9 and 2012. One suspects that this happened as a result of the criticism as well as pressure from higher levels, which created a committee in 2009 (chaired by a former APA president, Carolyn Robinowitz) to oversee the entire process. Frances and Spitzer (2009) also complained that no one outside the committees had access to the data driving the revision. In DSM-IV, the driving principle was that any changes must be justified by evidence. That evidence was summarized in a four-volume “sourcebook” (Widiger et al., 1997), put out a few years after the revision. There are no plans to publish a similar document for DSM-5. Instead, one could have consulted the website, in which changes were explained and justified with reference to the scientific literature. But when preliminary reports from the workgroups were posted in February 2010, they offered only brief rationales, not detailed literature reviews, data analyses, or critical comments about criteria. This vagueness suggested that some of the revisions were based on opinion rather than data, as happened in previous editions (Lane, 2007). Being vague deflects comment and prevents researchers not on the task forces from making informed critiques. Moreover, proposals were not sent to potential opponents to avoid bias—as had been the policy in DSM-IV (First, 2010). Moreover, the document as a whole was not presented to experts entirely outside the DSM-5 process for independent assessment. Because peer review is a basic principle in science, DSM-5 risks being less scientific than its predecessors. Many academics had their first good look at the proposed changes in February 2010. By the time the website opened, the process was well advanced, and workgroups had been meeting for 2 years. Although some changes were made after that, the train had already left the station. Moreover, all the rationales for changes were removed from access when the website was shut down a few months prior to the publication of DSM-5. Perhaps the real problem lay not in the process but, rather, in the fact that DSM-5 is more driven by ideology than previous manuals. The guiding principles are that mental disorders are neurobiological and dimensional and that they lack a cutoff from normality (Kupfer EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 40 | Part I Diagn ostic P ri n cip l e s & Regier, 2011). The agenda was to overthrow the neo-Kraepelinian paradigm. But although changes could be rationalized by empirical findings, the data were not sufficient to support these ideas. DSM-5 could not be a paradigm shift, and those who originally thought it could be were guilty of hubris. A more serious objection was that DSM-5 lacks clinical utility. The academics who wrote it may not have slaved away, like most of us, in a clinic or emergency room for years but, rather, spent much of their careers in front of computer screens. That is why they have not given the proper weight to clinical practice. This circle might have been squared if DSM-5 had been published in two versions—one for daily clinical use and one for research. That idea has been supported by some commentators (McNally, 2011) and seems sensible. But for the APA, dividing DSM-5 in two has no traction because it would be seen as compromising scientific cachet. In the end, DSM-5 made the same mistake one sees in many decisions made by governments or corporations. Without criticism from outsiders, “groupthink” takes over (Janis, 1972). We have often seen this happen in political decision-making, ranging from the Bay of Pigs to the invasion of Iraq. From my own knowledge of colleagues who served on the workgroups, I think some of them signed on to changes they did not really believe in to achieve a consensus. A Cautionary Tale One of the most serious omissions in the process of creating a new manual is the absence of any direct comparisons between DSM-IV and DSM-5, accompanied by an assessment of the clinical and research impact of changes. The omission was deliberate because the editors viewed DSM-IV as invalid and did not see any value in head-to-head comparisons. Moreover, the task force made a point of not consulting either Allen Frances, the editor of DSM-IV, or Robert Spitzer, the editor of DSM-III. Many other senior figures in psychiatry were left out of the loop. Leaving experts out of a process, and EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 3 H ow D i a gnos ti c M a n u a l s A re M a d e | 4 1 not even asking their opinion, was unwise. It led in some cases to open opposition (through both the scientific literature and the public media). The belief of the leadership was that the time had come for radical change and that although outsiders might disagree with changes, they would eventually have to come around—as they did after DSM-III. But there was a price to be paid. The DSM-5 process downplayed continuity (First, 2010). The most radical revision proposed was for personality disorders, a diagnostic group viewed as a poster child for dimensionalization (see Chapter 14). Although some degree of change was warranted, the proposed revision was unwieldy and problematic. It was openly criticized by a member of the workgroup (Livesley, 2010) who went on to resign in protest. The new criteria were certainly contentious. Every time they were presented at conferences, researchers who were not on the task force attacked these proposals. The response to these critiques was almost always along the lines of “you don’t really want to keep DSM-IV, do you?” Anyone who suggested leaving things more or less as they were until more evidence became available could be written off as a dinosaur. I was one of those left out of the process, but my criticism was not based on personal pique. After all, the opinion of most senior investigators in my area was never formally solicited. Anyone with opinions that might have contradicted the agenda was simply not heard. The result was that experts who were not included turned against the proposals, albeit for different reasons. Opponents, even as their suggestions were rejected, were forced to write articles in journals and/or letters of protest to the APA. The only way to exert any influence on the process was informal, through personal relationships with workgroup members. I wrote some workgroup members and even organized colleagues for a conference call with the chair of the personality disorder task force. A few minor changes we lobbied for did find their way into the final document. But in the end, the final proposal remained deficient in scientific support and in clinical utility, leading ultimately to its rejection. This is not the best way to prepare a diagnostic manual that would shape clinical work and research for many years to come. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 12/4/2019 1:26 PM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5® Account: s6527200.main.eds Copyright 2015. Oxford University Press. All rights reserved. May ...
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Introduction
DSM Is Diagnostic and Statistical Manual of Mental Disorders used by psychologists America
Psychiatric Association.
It is a manual that deals with classification, diagnostic of mental disorders. Before 1980,
diagnostic of mental disorders was done abstractly. There are several editions of this Manual
after 1980, a breakthrough was found that reliability on ''a theoretical'' clinical impressions that
means that making a diagnosis based on what clinicians and psychologists agree on. There had
no major changes until 1987 when DSMS-III R that had a greater degree of diagnosis including
bipolar II disorder and DSMS-IV published in 1994 that included attention deficit hyperactivity
disorder in adults.
DSMS -5- and Neuroscience
Neuroscience has shed much light on how the brain functions and this has been abstract to
analyses the etiology or pathogenesis of severe mental disorders. They agree that
psychopathology is caused by changes...


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