Thursday, July 30, 2009

The DSM-V Flap

It is troubling to discover demonizing polarization in discussions of DSM-V. It has been bad enough witnessing such primitive splitting in our political life.

While Dr. Frances (“A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences,” Psychiatric Times, June 26, 2009) raises legitimate concerns regarding the "unintended consequences" of major diagnostic reform, he never fully acknowledges the present consequences of DSM-IV. His recommendation that we wait until biological etiologies are more certain is both overidealizing of neuroscience and underestimating of the unintended damage being done with check list diagnoses of DSM-IV. The main function of a diagnosis is to maximize accurate perception and therapeutic efficacy. The false clarity of many DSM-IV categories no longer serves these goals. A nosology of symptoms has neither adequate biological nor psychological coherence in light of the past 40 years of clinical and research knowledge.

As is well known, the DSM emerged from the needs of pharmacologic research that required standardization depending on diagnostic consistency and international consensus on criteria. Unfortunately, the definition of disorders designed for this research took on the status of medical disorders like strep throat. Single transmitter theories predominated. An insidious reductionism resulted both within and outside psychiatric practice. Today, DSM-IV diagnoses are taught to medical students for “biopsychosocial” competence. Students are lead to believe the entities (developed 40 years ago) are naturally occurring disorders, not approximate symptom clusters established for drug trials. Primary care docs (who prescribe the majority of psych meds) rely exclusively on simplistic screening tools and check lists to direct treatment. Insurance companies require documentation of “biologically based” disorders for payment.

An “unintended consequence” of DSM-IV (even with the 5-axis diagnosis) has been a mishmash of pseudo-scientific reasoning. Steven Rose noted at a Novartis symposium that no MD would say a fracture, relieved by codeine, is a codeine deficiency disorder. Yet, our psychiatric nosology often reinforces this reductionism by implying each disorder is a specific “chemical imbalance” with a fixed set of behaviors that should be corrected by the right medication (e.g., if DA blockers reduced auditory hallucinations, then the disease called schizophrenia is a DA excess disorder; if an SSRI modulates some obsessional symptoms, it must be a 5HT deficiency.)

Unlike Dr. Frances, I would not await imagined certainties of neuroscience before reforming DSM. No matter what brain event we observe, the risk of faulty attributions of cause would persist. (Pharmaceutical companies would exploit any system to sell their products—dimensional or categorical.). Moreover, psychiatry has a mixed record when biological models prevailed (see: insulin coma, prefrontal lobotomy, neurotoxic drugs, etc.). Recent biological muddles (predicting resilience with long vs. short 5HT alleles, the ongoing search for a genetic marker for schizophreniform disorders, dexamethasone suppression tests) should make us skeptical about awaiting a neuroscience Rosetta Stone.

Other problems of current diagnostic approaches include:
– undertreatment of psychiatric patients for medical problems
– undertreatment of medical patients for psychological problems
– pejorative use of somatization in addressing pain or psychological coping
- pejorative use of “personality disorder” diagnosis
– replacement of in-depth interview and formal mental status examination with impressionistic assessment derived from a few symptoms
– failure to conceptualize a variant on PTSD in many medical and surgical patients who experienced shocking pain or sudden disability
- failure to address a patient's amalgam of inheritance, attachment, environment, mood, behavior, fantasy, and the unique adaptation of a personality to life events

We will always need to discover our patients in an individualized, dimensional, and interpersonal field to honor human reality; no fMRI, mirror neuron, or serotonin allele can supplant a true dimensional matrix.

The newer models that recognize the interplay of gene and environment provide a better perspective; the understanding that 5HT modulation is helpful in almost all categories of illness—targeting many different CNS regions with distinct 5HT receptors and functions—has moved science away from the one disorder/one medicine hype so popular with pharmaceutical marketeers. Dubovsky and Stahl have long clarified the inadequacy of “chemical imbalance” models and how symptoms actually cluster and evolve within a complex individual context. The categorical model is no longer sufficient to guide much prescribing or psychological treatments.

Although Dr. Frances seems to denounce the DSM-V team as one in an ivory tower, their new dimensional approach responds to decades of clinical observation. The actual mix of mood, relational style, thought process, and functioning should be essential to our diagnostic framework and not relegated to charting a 5-axis discharge diagnosis. I have been in private practice for 30 years and have struggled to make many of my patients “fit” into a DSM-IV category. Axis 2 diagnoses—poorly conceptualized in DSM-IV—trigger insurance denials. It is ironic that insurers have stigmatized axis 2 even though there is reason to believe these complex patients require repeated costly hospitalizations. Biological parity forces overuse of “bipolar,” which in turn promotes prescribing expensive and toxic mood stabilizers—some with serious adverse effects—often with little substantive benefit, which in turn stirs more “aggressive” polypharmacy. Only quite recently have interpersonal treatments attracted mainstream research attention despite the years of Big Pharma promoting Bipolar Disorder and ADHD.

The study of early life stress and adult pathology is helping to close the bio-psychological divide, but has little traction in DSM-IV.

So while I am grateful for the caution Dr. Frances promotes I fear it may hamper the development of DSM-V. Clinicians have been trapped for too long with an antiquated manual into which patients are squeezed; sometimes damaged by the illusion that the diagnosis they've been given exists as a real entity with a simple cure.Better we give more than false clarity; let's hope DSM-V will help us see what is rather than starting with a category within which we must locate our patients.

Sara Hartley, MD
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Tuesday, July 21, 2009

Dr Rosenblum speaks up regarding APA's response to Dr Frances

Dr Stephen Rosenblum, Life Fellow, APA writes:

"I found the American Psychiatric Association's response ("Setting the Record Straight", Psychiatric Times, July 1,2009) to Dr. Alan Frances's commentary ("A Warning Sign on the Road to DSM-V", Psychiatric Times, June 26, 2009) outlining his concerns about the DSM-V an embarrassing, black mark against the Association. As President of an organization supposedly devoted to scientific objectivity, Dr Alan Schatzberg's (lead author of the response) ad hominem attack and use of unprovable innuendos to discredit Dr. Frances reflects an approach I want nothing to do with.

If Dr. Schatzberg and his coauthors need an example of a professional, objective and scientific response to Dr. Frances they should refer to Dr. William T. Carpenter's commentary "Criticism vs. Fact" (Psychiatric Times, July 7, 2009, or to Dr. Renato D. Alarcon's essay "Inside the DSM-V Process: Issues, Debates, and Reflection." Both authors counter Dr. Frances's arguments without attacking him personally.

I can only assume that as President of the APA, Dr. Schatzberg reperesents the mind set of our organization. If that is so, it is an organization with which I take no pride in my affiliation." Read more!

Thursday, July 16, 2009

Doctor, Are You "Drugging" or Medicating Your Patients? Antipsychiatry and the War of Words

You have read the blogs and seen the placards a dozen times: doctors prescribe too many “drugs” for too many patients. Psychiatrists, in particular, are popular targets of politically-motivated language that seeks to conflate the words “medication” and “drug”—thereby tapping into the public’s understandable fears concerning “drug abuse” and our need to carry out a “War on Drugs”. Misleading radio ads promise “drug-free” treatment of panic disorder (certainly possible, but not always achievable) and the Internet bristles with the phrase, “psychiatric drugging” (my Google search pulled up 9,310 results). And, all too predictably, any physician who argues that psychotropic medication is often an effective and life-saving intervention is hustled off to the perp-line of “drug company shills.”

All this will not surprise students of language, history, and philosophy. Those who control language are well-positioned to control thought and behavior. If government officials can persuade the public that killing innocent civilians is merely “collateral damage”, they have gone a long way toward justifying the carpet-bombing of a village. If the forces of anti-psychiatry—and they are alive and well—can persuade the public that psychiatry is “drugging” people, they have gone a long way toward marginalizing and discrediting the profession. To understand how powerful the words “drug” and “drugging” are, imagine the feckless campaign that would be waged if the perennial protesters in front of the APA’s Annual Meeting carried signs that read, “Psychiatrists: Stop Medicating Your Patients!”

Is this all merely a matter of “semantics” or—in the parlance of post-modernism—“competing narratives”? Is there any scientific reason to distinguish “drugs” from “medications”? And finally, what are our ethical obligations as healers when medication is administered, either voluntarily or involuntarily? I will have more to say on these matters in a more detailed version of this blog, and in a follow-up piece on the considerable good that psychiatric treatment can do.

Yes, one can argue that, in today’s setting of “mis-managed care,” psychotropic medication is sometimes prescribed too readily, when psychotherapy would be the preferred treatment. And, yes: we need more effective medications in psychiatry, used in more judicious ways--particularly in children, adolescents, and those with dementia, for whom our evidence-base is often shaky. We should be wary of attempts to expand both our disease categories and the labeled indications for psychotropic medications.

Finally, let there be no doubt that, as physicians and healers, psychiatrists have an ethical responsibility to see that medications are prescribed and administered in a compassionate and non-coercive way, consistent with the principles of informed consent and respect for personal autonomy.

But to lump all psychotropic medications in with drugs of abuse is to embrace junk science and junk rhetoric. Psychiatrists need to find a gentle but persuasive language of resistance, in the face of this ploy.

Ronald Pies, MD, Editor-in-Chief
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Tuesday, July 14, 2009

Resignation Letter to DSM-V Workgroup

Dr Jane Costello, PhD, professor in the department of psychiatry and behavioral sciences at Duke University and former DSM-V Workgroup member resigned from the Child and Adolescent Workgroup in March after feeling that the development of the new edition was off-track. Dr Costello shared the letter she sent to Workgroup leader, Danny Pine, MD (NIMH). A copy of the letter she sent follows.

Dear Danny;
As we discussed at the DSM-V meeting last week,
I am resigning from the Child and Adolescent Disorders workgroup. As you know, I
have been thinking about this for some time, but have been reluctant to take
this step because I very much enjoy working with this extraordinary group of
people, and learning so much from them. However, I cannot in good conscience
continue. These are my reasons:

1. I am increasingly uncomfortable with the
whole underlying principle of rewriting the entire psychiatric taxonomy at one
time. I am not aware of any other branch of medicine that does anything like
this. (The ICD revisions make no attempt to rewrite the details of each
diagnosis.) There seems to be no good scientific justification for doing this,
and certainly none for doing it in 2012.

2. When we began this process, we
agreed that changes would only be made if there were empirical evidence to
support them. Sometimes (as with Charlie’s [Charles Zeanah, MD, Tulane
University] work on preschool PTSD) this has been the case. But as time has gone
by, the gap between what we need to know in order to make revisions and what we
do know has grown wider and wider, while the time to fill these gaps is
shrinking rapidly. More and more, changes seem to be made for reasons that have
little basis in new scientific findings or organized clinical or epidemiological

3. Efforts by Pat Cohen [Patricia Cohen, Ph.D., Columbia University]
and myself in 2007 to provide data to fill some of the gaps in the knowledge
base were rejected. One reason given by David [David Kupfer, MD, Univeristy of
Pittsburgh] was that the answers to questions were needed within 6 months, i.e.,
by the end of 2007. Now Prudence’s [Prudence Fisher, Ph.D., Columbia University]
grant has a favorable review and may be funded by the fall of 2009, with data
available perhaps in 2010. As far as I am aware there is not yet a process in
place for feeding to Prudence the questions that the data sets could be used to
answer, so any results are likely to be even more delayed. This, as we have all
agreed, makes no sense.

4. One reason why it took so long to get a data base in
place was that a decision was made that the work had to be done via a grant
application to NIMH, with all the time delays entailed by that process. The
reason given was that the funding allocated by the APA for research for DSM-V
was not enough to support the necessary work. I continue to be shocked that the
APA would even consider revising the DSM without being willing to allocate the
funding necessary to carry out the underlying scientific studies. A drug company
that tried to bring a product to market on the basis of inadequately-funded
research would rightly be censured. This is what the APA is doing, and now that
it is quite clear what is happening I am afraid that I cannot bring myself to be
part of the process any longer.

5. The tipping point for me was the memo from
David and Darrel [Darrel Regier, MD, American Psychiatric Association] on
February 18, 2009, stating “Thus, we have decided that one if not the major
difference between DSM-IV and DSM-V will be the more prominent use of
dimensional measures in DSM-V”, and going on to introduce an Instrument
Assessment Study Group that will advise workgroups on the choice of old scale
measures or the creation of new ones. Setting aside the question of who
“decided”, on what grounds, anyone with any experience of instrument development
knows that what they proposed last month is a huge task, and a very expensive
one. The possibility of doing a psychometrically careful and responsible job
given the time and resources available is remote, while to do anything less is

It has taken me a long time to reach this conclusion,
largely because I greatly value and enjoy working with you and the workgroup,
and respect your commitment to the DSM-V process. I honor your position – that
given DSM-V is going to be written, the best people should do it. You know that,
as always, I am ready, as in the past, to carry out any data analyses that could
be helpful to your decision-making on specific issues. Please give my greetings
to the rest of the workgroup, and feel free to share with them as much of this
as you choose.

Read more!

Wednesday, July 8, 2009

Frances and Spitzer: A Message to DSM-V Workgroup

Drs Spitzer and Frances sent over the following in response to Dr Renato Alarcon's article, "Inside the DSM-V Process: Issues, Debates, and Reflections" (Psychiatric Times, July 2009, p 1).

We have no argument at all with any of the DSM-V work group members, all of whom undoubtedly have the best of intentions and are working hard to do a good job in revising the diagnostic system. Indeed, we are pleased that Workgroup members have often made their own efforts to engage in discussions with their colleagues and are making presentations about their work at meetings.

Instead, our problem is with the conditions imposed on the work group members by the DSM-V leadership, particularly: (1) the confidentiality agreements; (2) the unwillingness to post on the DSM-V Web site the work done so far by the workgroups (i.e., the literature reviews, results of any of the secondary data analyses, and, most importantly, the exact wording of the proposed criteria sets or dimensions; and (3)the rush to prematurely start these field trials in order to meet an artificially imposed publication deadline.

The basic, obvious, and unanswered question is how can field trials begin now before any of the DSM-V options and supportive literature have been posted and time given for a thorough critique from the entire field? Would it not help Dr Alarcon and other work group members to get input from the largest possible number of reviewers before deciding on which suggestions deserve to move forward and which have too many previously unrecognized risky unintended consequences? Would Dr Alarcon and other work group members not prefer to be given sufficient time to make sure that DSM-V is as problem-free as possible?

There is no justification for a fixed publication date in 2012 now that ICD-11 will not appear before 2014. Let's have everything posted and thoroughly reviewed first, and then it will be appropriate to plan field trials. We wrote to the American Psychiatric Association Board of Trustees precisely to help ensure the best possible environment for the efforts of Workgroup members like Dr. Alarcon - an environment unconstrained by confidentiality agreements, artificial time pressures, and lack of external input. We wish him (and all the DSM-V Workgroup members) well in their continued work on DSM-V.

Allen Frances, MD and Rober Spitzer, MD
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Monday, July 6, 2009

Calling all Psychiatrist-Artists

Psychiatric Times is collecting a library of images to use to illustrate our articles in print or online.

If you would like your artwork to be considered for inclusion in our image library, please e-mail us a high-resolution file (TIFF, JPG, EPS, PDF - no more than 10mb) along with the title of the work and the medium used. Images will be reviewed by the editors and accepted art will be used online or in print to illustrate articles in Psychiatric Times. Your byline and contact information will be included. Psychiatric Times will have nonexclusive rights to reproduce the accepted image either in print or online. Artists will retain the right to sell or use the image as they see fit. Read more!

Thursday, July 2, 2009

APA Responds to Dr Frances

On Wednesday, the APA submitted a formal response to Dr. Frances' commentary, "A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences Here's an excerpt:

"The process for developing DSM-V has been the most open and inclusive ever. The process began with a planning session that led to 13 NIH-supported international research conferences and a series of monographs. These conferences included more than 400 scientists, clinicians and others in the field. The DSM-V Task Force and Work Groups include more than 150 experts in various specialties and sub-specialties from 16 countries, including both scientists and clinicians. Over 200 advisors have thus far been asked to share expertise with DSM Work Groups. The DSM-V Task Force established a Web site,, to accept comments and provide work group updates. Unfortunately, to bolster his unjustified ad hominem attacks, Dr. Frances used the readily available DSM-V updates and misrepresented them as final decisions, rather than as statements of work in progress."

Read the rest of the article and send us your comments.
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