DSM5Preamble & Critique

Dr (Maj) Ashutosh Ratnam

Overview • The Felt Need for DSM5 • Revision Process – Work groups – Proposals for Revisions – Field Trials – Reviews

• Cultural Issues • The Multiaxial System • Definition of a Mental

Disorder

• Organisational Structure – Dimensional Diagnosis – Developmental / Lifespan

Approach

Definition – Preamble

• “an introductory statement; especially the introductory part of a constitution or statute that usually states the reasons for and intent of the law”

Merriam-Webster

• “an introduction to a document, speech, or report explaining its purpose”

• Macmillan English Dictionary for Advanced Learners

The Felt Need for DSM5 • “…past science was not mature enough to yield fully

validated diagnoses – i.e. to provide consistent, strong and objective scientific validators of indl DSM disorders”

• “Speculative results do not belong in an official nosology, but DSM must evolve in the context of other clinical research initiatives”

• “The boundaries between many disorder ‘categories’ are more fluid over the life course than DSM-IV recognized”

• “Many symptoms assigned to a single disorder may occur, at varying levels of severity, in many other disorders”

The Revision Process•American Psychiatric Association •WHO Division of Mental Health •World Psychiatric Association •National Institute of Mental Health •“Stimulate research that would enrich the empirical database before the start of the DSM-V revision process” •“Devise a research and analytic agenda that would facilitate the integration of findings from research and experience in animal studies, genetics, neuroscience, epidemiology, clinical research, and crosscultural clinical services”

“It can be concluded that the field of psychiatry has thus far failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder or for predicting response to psychopharmacologic treatment”

“Such an accomplishment would help move the specialty into the mainstream of modern medicine, where etiology and pathophysiology have replaced descriptive symptomatology as the fundamental basis for making diagnostic distinctions”

The Revision Process

•American Psychiatric Association •WHO Division of Mental Health •National Institute of Mental Health •National Institute on Drug Abuse•National Institute on Alcoholism & Alcohol Abuse

Preparing for Revisions to •DSM5•ICD-11

David Kupfer, MD •Thomas Detre Professor of Psychiatry•Professor of Neuroscience and Clinical and Translational Science University of Pittsburgh School of Medicine

Darrel Regier, MD •Senior Scientist, Center for the Study of Traumatic StressDepartment of PsychiatryUniformed Services University

Diagnostic Working Groups • ADHD and Disruptive

Behavior Disorders • Anxiety, Obsessive-

Compulsive Spectrum, Posttraumatic, and Dissociative Disorders

• Childhood and Adolescent Disorders

• Eating Disorders• Mood Disorders• Neurocognitive Disorders

• Neurodevelopmental Disorders

• Personality and Personality Disorders

• Psychotic Disorders• Sexual and Gender Identity

Disorders• Sleep-Wake Disorders• Somatic Symptoms Disorders• Substance-Related Disorders

Working Groups 1. Revisions must be feasible for routine clinical practice 2. Recommendations for revision should be guided by

research evidence 3. When possible, continuity should be maintained with

previous DSM editions 4. No a priori constraints should be placed on the degree of

change from DSM-IV to DSM5

• Change Diagnostic Criteria • Add new disorders, subtypes & specifiers • Delete Existing Disorders

Field Trials 1. Medical/Academic

Settings Large sample sizes required to test diagnostic hypotheses on •reliability •clinical utility

2. Routine Clinical Practice (RCPs)

Tested how proposed revisions performed in everyday clinical settings when used by a range of clinicians (General + speciality psychiatrists, Psychologists, Counselors, Therapists, Nurses)

Field Trials – Medical/Academic• New York State Psychiatric

Institute, Columbia University Medical Center, New York

• Baystate Medical Center, Springfield, Mass

• Children's Hospital, Aurora, Colo

• Lucile Packard Children's Hospital, Stanford University in Stanford, Calif.

• Department of Veterans Affairs, Dallas

• University of California, Los Angeles

• University of Texas Health Science Center, San Antonio

• University of Pennsylvania, Philadelphia;

• Mayo Clinic, Rochester, Minn

• Centre for Addiction and Mental Health, Toronto

• The Menninger Clinic, Baylor College of Medicine, and the DeBakey VA Medical Center in Houston.

Consenting

Patient

Screened for DSM-

IV Diagnoses

Likely to predict specific DSM5

disorders of interest

Stratified Sampling

of patients

for4-7

specific disorders

Patients fill CAI

of Cross-Cutting Sympto

ms

Scored Results

Provided to

interviewers

CLINICAL

INTERVIEW #

1

CLINICAL

INTERVIEW # 2

Calculation of

Kappa

Statistic

CLINICAL INTERVIEW•Presence of qualifying criteria on CAI of DSM5 checklist •Determine Diagnosis •Score Severity of Diagnosis

Public/Professional Review

• All draft criteria & proposed changes posted to www.dsm5.org for 02 mth comment period (2010)– 8000 submissions systematically reviewed by work

groups – Comments integrated into discussions for revisions and

field trial plans • After revisions + proposed chapter organisation – Second posting in 2011 – Third posting 2012

WORK GROUPS

SCIENTIFIC REVIEW COMMITTEE

Review recommended

revisions based on strength of

supporting scientific data

CLINICAL & PUBLIC HEALTH COMMITTEE

Regarding criteria deemed inadequate

by SRC •Consider additional clinical utility •Public health issues•Logical clarification

APA Council on Psychiatry and Law

DSM5 TASK FORCE

APA Board of TrusteesAPA Assembly’s Committee on DSM5

Dimensional Approach to Diagnosis• Previous DSMs considered each diagnosis separate

from health and other diagnoses – Failed to capture widespread sharing of symptoms and

risk factors across many disorders – Focused on excluding false positive results

• Diagnostic spectra study group examined if scientific validators could inform possible new groupings of related disorders – Within existing categorical framework– Used to suggest grouping of disorders, e.g. internalising

v/s externalising

Dimensional Approach to Diagnosis

• Shared Neural substrates

• Family traits • Genetic Risk Factors • Specific Environmental

Risk Factors • Biomarkers • Temperamental

antecedents

• Abnormalities of emotional or cognitive processing

• Symptom Similarity • Course of Illness • High co-morbidity • Shared treatment

response

Developmental/Lifespan Considerations• DSM5 organisation – Begins with diagnoses thought to reflect developmental

processes manifesting early in life • Neurodevelopmental, Schizophrenia Spectrum

– Followed by diagnoses manifesting in adolescence / young adulthood • BPAD, Depressive & Anxiety Disorders

– Ends with diagnoses relevant to adulthood & later life • Neurocognitive

• Grouping of disorders after Neurodevelopmental into – Internalising – Externalising – Neurocognitive – Other Disorders

Developmental/Lifespan Considerations

• Encourage study of underlying pathophysiological processes giving rise to diagnostic comorbidity & symptom heterogeneity

• Facilitate identification of potential diagnoses by non-mental health professionals

• Guide clinicians to explain to patients why over a lifespan they recd– multiple diagnoses – additional / altered diagnoses

Cultural Issues • Judgment of given behaviour being abnormal and requiring

clinical attention depends on cultural norms • Awareness of culture may correct mistaken interpretations

of psychopathology • Culture may contribute to vulnerability and suffering • Culture may provide coping strategies to enhance resilience

& suggest help seeking /health care options of various types – Alternative & complementary health systems

• Influence acceptance or rejection of diagnosis and adherence to treatment

• Affect conduct of clinical encounter – Accuracy & acceptance of diagnosis, treatment decisions

Cultural Issues

• Culture Bound Syndrome replaced by

1. Cultural Syndrome 2. Cultural Idiom of Distress 3. Cultural explanation or perceived cause

The Multiaxial System

• DSM5 moved to a non-axial documentation of diagnosis – Separate notations for important psychosocial & contextual

factors (earlier Axis IV) and disability (earlier Axis V) • Consistent with DSM-IV stance that the multiaxial system DOES

NOT imply that – There are fundamental differences in the conceptualisation of Axix

I, II or III disorders – That mental disorders are unrelated to physical/biological factors – That general medical conditions are unrelated to behavioural /

psychosocial factors or processes • Consistent with WHO and ICD guidance to consider indl’s

functional status distinct from diagnostic/symptomatic status

Defining a Mental Disorder • A mental disorder is a syndrome characterised by

clinically significant disturbance in an indl’s – Cognition – Emotional regulation – Behaviour

• that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning .

• Mental disorders are usually associated with significant distress or disability in social, occupational or other important activities

• An expectable or culturally approved response to a common stressor or loss (e.g. the death of a loved one) is NOT a mental disorder

Summary

• Efficient administrative machinery • Open process of review • Emphasis on empirical validation • Rigorous Field Trial Framework

DSM5 Critique

Definition – Critique

• “a careful written examination of a subject that includes the writer’s opinions”Macmillan’s Dictionary

• “a report of something such as a political situation or system, or a person's work or ideas, that examines it and provides a judgment, especially a negative one”Cambridge English Dictionary

DSM5 Timeline

2009 2010 2011 2012 2013 2014

Phase 2 Sched End, Phase 1 actually ends

Feb 12

Phase 2 sched StartSep 11

Phase 1 actually

startsJune 2010

Academic Insitutue Phase 1

scheduled start

June 2009

Scheduled Phase 1

Scheduled Phase 2

Actual Phase 1

Failed Deadlines • Clinician Field trial – Aug 10 – scheduled to be trained by then – Dec 11 – training actually completed (14mths late)– Nov 10 – patients scheduled to be enrolled – Feb 11 – scheduled to finish trial 1

• “RCP field trials continued until after enrollment ended in February 2012. Work groups were provided with results from both field trials and updated their draft criteria as needed”

Kappa Statistic Discrepancies

Distortion of Kappa Values • According to the authors, of the 23 disorders – 14 had “very good” or “good” reliability– 6 had questionable, but 'acceptable' levels– 03 had “unacceptable” rates

• Only 5 of the 23 DSM 5 diagnoses that achieved kappa levels of agreement between 0.60–0.79 would have been considered 'good' in the past

• 9 DSM 5 disorders in the kappa range of 0.40–0.59 previously would have been considered poor (DSM 5 calls these 'good')

• 3 diagnoses that were below <0.20 (which is barely better than chance) are found unacceptable

Questionable Quality of Field Trials

•Major Depressive Disorder •Generalized Anxiety Disorder• GAD - DSM 5 definition was so very poorly done

•DSM 5 had made no changes from the MDD definition • reliability has been repeatedly studied • always achieved rates twice as high

•? Incompetence in how the DSM 5 field trials were conducted•Throws in doubt all of the other results

Hypervigilance • Work group members sign confidentiality agreements to protect

DSM 5 'intellectual property‘• APA rebuffs calls from 51 mental health associations for an open and

independent scientific review• APA's legal office tries to stifle criticism and censor internet derision

– threats of trademark litigation• Original DSM 5 plan for field trials included no prior public viewing of

criteria sets and no period for public comment– These are added only under heavy outside pressure

• DSM 5 publishes no aggregations of key areas of concern identified during public reviews– Doesn't respond publicly to them– No indication that public input has had any impact whatever on DSM 5

• APA declares it will “post a complete set of DSM 5 reliability data in time to allow comments during the final period of public review”– NOT DONE

CONCLUSIONS• “Melancholia’s features cluster with greater

consistency than the broad heterogeneity of the disorders and conditions included in major depression and bipolar disorder

• The melancholia diagnosis has superior predictive validity for prognosis and treatment, and it represents a more homogeneous category for research study.

• We therefore advocate that melancholia be positioned as a distinct, identifiable and specifically treatable affective syndrome in the DSM-5 classification”

• “I believe you and your colleagues are fundamentally correct

• But the inclusion of a biological measure would be very hard to sell to the mood group

• The problem isn’t the test’s reliability, which I think is better than anything else in psychiatry.

• Rather, it is that the D.S.T. will be the only biological test for any diagnosis being considered”Dr William Coryell, Member, APA Assembly’s Committee on DSM5

Overdiagnosis • Binge Eating Disorder • Disruptive Mood Dysregulation Disorder • Removal of Bereavement Exclusion

• MDD K=0.32• Fewer than one-third of antidepressant users have

consulted a mental health professional in the past year• Four out of five prescriptions for psychotropic drugs are

written by practitioners who are not psychiatrists (Psychiatric Services, 2009)

• 72% of psychotropic drugs are prescribed without meeting a psychiatric diagnosis

• (Health Aff (Millwood). 2011 Aug;30(8):1434-42. doi: 10.1377/hlthaff.2010.1024. Proportion of antidepressants prescribed without a psychiatric diagnosis is growing)

• Persons who had a bereavement related depressive syndrome at baseline were no more likely over a 3-year follow-up period to have a major depressive episode than those who had no lifetime history of major depression at baseline.

• Subjects who had had an episode of major depression at baseline were significantly more likely to have a recurrence of depression during the 3-year followup than those without a history of depression or those who had only had bereavement-related depression.

• Mojtabai R. Bereavement-related depressive episodes: characteristics, 3-year course, and implications for the DSM-5. Arch Gen Psychiatry 2011;68:920-8.

• The majority of bereaved and clinically depressed patients are seen by primary care practitioners

• It is critical that such practitioners be skilled at distinguishing between clinical depression, which requires treatment, and uncomplicated grief, which is an entirely normal emotional response to loss.

Why the rush?

• “The need to coordinate DSM-5 with ICD-10-CM coding, which was scheduled to start Oct 2013”

• Health and Human Services (HHS) Secretary Kathleen G. Sebelius has announced that the start date for ICD-10-CM has been postponed. It is not yet clear for how long, but most likely a yearICD-10-CM Delay Removes Excuse For Rushing DSM-5 Into Premature Publication, Psychiatric Times, February 22, 2012

Summary • Poor Diagnostic Consistency• Empirical Groundwork was incomplete • Encourages overdiagnosis of mental illness • Ignored the ONE objective scientific validator

available • Rushed into implementation when time was

available for a completion of 2nd phase of trials • Validity of Psychiatry as a science undermined – Asperger’s removed completely

References • DSM-5 : How Reliable Is Reliable Enough? Am J

Psychiatry 169:1, January 2012• Grief, Depression, and the DSM-5 Richard A.

Friedman, M.D. N Engl J Med 366;20 May 17, 2012• DSM-5, American Psychiatric Association • A Research Agenda for DSM-V, APA • Issues for DSM-5: Whither Melancholia? The Case

for Its Classification as a Distinct Mood Disorder, Am J Psychiatry 167:7, July 2010