DSM-V: A Brief Conversation With Allen Frances

Having come across his email address I could not resist posing a question, and he honored me with a reply, alas another question. I thought the conversation might deserve public exposure.

My question:

"It has seemed to me that in general DSM criteria from 3 on have been necessary but not sufficient to make a dx. The clinician must make a judgement that the pt is ill, THEN use the DSM to classify that illness.

Would it help to emphasize that fact?"

Before I record Frances' response let me elaborate. Many years ago, during a deposition, an attorney pulled out the DSM and walked me through the criteria for some disorder one by one. I had to admit most if not all seemed to be met, at least at first glance, but I still opined that the patient did not suffer from the disorder. This raised a question I might have thought would have an obvious answer: According to the DSM, if the patient meets all the criteria, does that imply they have the illness? I have looked in vein for an answer. This led me to the conclusion that, especially given the Cautionary Statement at the beginning of the book, the proper way to apply the criteria might involve a trained clinician (not an attorney) first making the judgment that the patient suffers from a mental illness, and referring to the diagnostic criteria only to classify the illness, ie to determine which diagnosis fits best.

It seems to me that inclusion of a clear statement on this issue could improve DSM-V.

I figured if anyone knows the answer it must be Dr. Frances. His response:

"Do you mean by ill that the patient has clinically significant distress or impairment?" 

Gee thanks, doc. I think he may be trying to use this as a teachable moment. I believe this question is beside the point, but of course it is very critical.

"Clinically significant distress or impairment," in my opinion, does not qualify as the definition of a mental disorder. Rather it is a threshold. I find it hard to imagine making a diagnosis of mental disorder in the absence of clinically significant distress or impairment, but I hold out the possibility it might be appropriate in some cases. I'm still wondering why he asks. Maybe he just wants to know whether the process I describe above consists of first determining that there is clinically significant distress or impairment, then applying the criteria. Fair enough.

But that is not what I do. I believe there is more to identification of a diagnositc entity than distress or impairment. A disorder must somehow hold together and have a life of its own. It can't just mean feeling really bad or not functioning 100% when things are going rough for example (or did I just define adjustment disorder?).

The term "clinically significant" bothers me too. Does that just mean the problem was so bad the patient sought professional help, or that someone else thought they should seek professional help?

A lot of this debate struggles with determining just how clear the dividing line between normal and sick should be. We lose if we say everyone is sick all the time, or that everyone has an excuse for doing bad things or failing a responsibility. We also lose if we keep those who need it from accessing treatment.

If Dr. Frances responds again, I will post here.

Psychiatric Diagnosis: The Shorter Version?

If you believed half of the contradictory and baseless assertions of Edward Shorter (Why Psychiatry Needs Therapy, Wall Street Journal Feb 27-28, 2010) you might envision hundreds of thousands of healthy and symptom-free Americans flocking to psychiatrists after seeing themselves described in the new DSM-V and demanding treatment with expensive drugs. And continuing to take these drugs even when they reap no benefit from them.

Nothing could be further from the truth. In fact Shorter should know that many individuals that need help and might seek it, do not, in part because of the stigma that he perpetuates with his pejorative view of mental illness. And like other critics of psychiatry who see the APA's effort to improve on DSM-IV TR as an opportunity, he has failed to offer a better system of categorizing a very real group of individuals who suffer very real symptoms. Few patients continue taking medication unless they feel a definite benefit. And many improve with psychotherapy, ECT, and other treatment modalities.

I will start with the catchy photos at the bottom of the page under the heading "The New Abnormal."

Hoarding: The definition may be new, but the problem is not. What would Shorter have us do with those who want help for this problem?

Mixed Anxiety-Depression: He says himself this combination has been recognized for years. The only new thing about it is its addition to the Manual. Make up your mind, Shorter.

Binge Eating: New? Not! Shorter, you can tell people who want help with this to stop complaining, just control yourself and go away. I can't.

Minor Neurocognitive Disorder: He calls this a commonplace occurrence for anybody over 50. We should not diagnose and treat that which is commonplace? Like the common cold? Like buponic plague? malaria? TB? Last I heard most people in the world suffered from parasitic illness, that's pretty commonplace. Shall we forget about them, too?

Temper Dysregulation Disorder with Dysphoria: He says it's a new way to diagnose fewer kids as bipolar. That's wrong? Perhaps he would have us believe the problem doesn't exist.

Shorter seems to like diagnoses in use in the 50's and 60's he relates to the European scientific tradition, but offers no support for his suggestion that they might have been more "accurate." In fact the diagnoses prior to DSM-III were based largely on very UNscientific psychoanalytic theory, and did not include "nerves" or "nervous breakdown" as he would have us believe. These ill-defined terms from popular language are almost meaningless. Shorter implies that because lithium "sometimes" prevents depressive episodes we should not bother to differentiate bipolar disorder from unipolar mood disorders ignores evidence that some drugs do treat unipolar depressive episodes effectively, and may exacerbate bipolar disorder.

Shorter's assertion that the "new" disorders all respond to the same drugs is not only baseless, but contradicts his later statements that the drugs do not work. He claims that imipramine remains the most effective drug for what he calls "serious" depression. (It also happens to be dangerous in overdose and to have more adverse effects at therapeutic doses than newer agents, many of which cost as little as $10 for a 3 month supply.) Please note that Shorter offers no definition of this category has conjured up on his own, nor any criteria for determining whether someone suffers from it or not. Perhaps we should rename it "Shorter's Disease," but that would be yet another "new" abnormal.

Benzodiazepines: An "undeserved reputation for addictiveness"? In addiction psychiatry we call this denial. I call these drugs practice builders because patients like to keep coming back for more. Has assertion that they are "effective across the entire range of nervous illnesses" is ridiculous, made even more so by the fact that, once again this Shorterism, "nervous illness," has no definition. It doesn't seem to have occurred to Shorter that the large number of prescriptions written might support the idea that many patients become addicted to them.

Shorter would have us believe that DSM-III was a step backward for psychiatry but he fails to mention that it finally dumped psychoanalytic theory and gave us the new phenomenon of multiple psychiatrists examining the same patient actually giving the same diagnosis. This inter-rater reliability was almost non-existent in earlier diagnostic schemes.  Shorter would have us believe that "bipolar" was a new diagnosis. In fact it was just a new name for what was previously called manic depressive illness. Now he tells us what "experienced clinicians" know. And where did you get that piece of information Mr. Shorter? Did you conduct a pole? Do tell us what constitutes an experienced clinician. Would we (or they) really all agree that patients with "chronic depressive illness" (another undefined Shorterist category, thank you very much) "will have" an episode of mania or hypomania? But Mr. Shorter, "mania" and "hypomania" are both defined in the DSM's. Or would you like to propose your own criteria? Or maybe you don't like criteria at all.

Shorter's statement that "anxiety became associated with addiction" doesn't even make sense.

Shorter says that "Major depression" (Does he mean Major Depressive Disorder or Major Depressive Episode?) became the "big new diagnosis." If by this he means that the frequency with which it was diagnosed increased dramatically, I agree, but this may have resulted from changes in reimbursement by insurance companies, another factor Shorter ignores in this discussion.

Shorter assets that SSRI's "don't work for diseases that don't exist." I believe a lot of patients would say otherwise.

If Mr. Shorter this half his students exhibit "disorganized speech" he may not know what it really sounds like. As for "psychosis risk syndrome" identification of at-risk populations may lead to prevention. Shorter would have us pretend such patients don't exist. Even worse he implies that if we don't have "specific treatments" for a disease we should ignore it.

I confess I cannot make sense of Shorter's closing paragraph, but I will resist the temptation to identify it as disorganized speech. What does he mean by what patients "actually have?" Why should we believe the "European tradition" he esteems is so great? And what is it anyway?

Mr. Shorter, all of psychiatry is like drawing "lines in a bucket of water," but that doesn't mean we should give up. Your ideas must be very popular in Canada, where the idea of all these people needing help must incite fear of bankrupting your health care system, but don't you just put them all on the waiting list anyway? or diagnose them all "nervous illness" and give them all benzodiazepines.

Sally Satel and DSM-V

See Sally Satel's article in Wall Street Journal 2.19.2010 Prescriptions for Psychiatric Trouble

OK, Dr. Satel, it ain't perfect, but it won't get better unless we keep trying. Dr. Satel gives in to the temptation to take pot shots and gives no praise to the latest effort by the American Psychiatric Association to classify mental, behavioral, and emotional problems and offers no suggestion whatsoever of how we might do better.

She criticizes the new Psychosis Risk Syndrome claiming that "a diagnosis believed to foreshadow a full-blown psychotic illness has the potential to be highly stigmatizing." Is not prognosis a major task associated with diagnosis for physicians? And who has stigmatized "full-blown psychotic illness?" Perhaps Dr. Satel herself has done so. Society stigmatizes psychiatric diagnoses. Don't shoot the messenger, Dr. S.

Dr. Satel goes on to say it might be "especially unfortunate if the labeled individual does not even go on to develop such and illness." That's like saying it is unfortunate if someone involuntarily hospitalized because of suicide risk does not commit suicide. I say it's very fortunate if the person so labeled does not go on to develop the illness, especially if the label leads to intervention that plays a role in altering the course. And speaking of stigma, note that Dr. Satel has substituted the pejorative term "label" for diagnosis or classification. So diabetes is a diagnosis, but "Psychosis Risk Syndrome" is a label?

Dr. Satel calls "stunted sexual development" a Freudian concept?  Does she mean "psychosexual development?" Even Freud did not refer to it as "stunted." Freudian theories have certainly failed to meet scientific muster, but Dr. Satel seems to miss the point that before DSM-III there were no diagnostic criteria based on phenomena, just descriptions. And terms like neurosis implied unproven Freudian causes.

Major depressive disorder is not, as Satel claims, the sole designation for "pathological depression," which in fact encompasses numerous disorders such as Dysthymic Disorder, Adjustment Disorder with Depressed Mood, and others. She asks, "How do we know it is not a normal reaction?" Read the criteria doc. It's spelled out clearly. Dr. Satel may also have failed to read the Cautionary Note at the beginning of the DSM. I guess if you're suffering but she doesn't "know it's not a normal reaction" Dr. Satel will refuse to help you.

Dr. Satel rightly suggests that the "causal mechanisms" of mental illnesses might be staggeringly complex, but she fails to state that such mechanisms have yet to be defined at all. Would you have us wait until we know the mechanisms before we classify the disorders -- or treat the patients who suffer from them?

Dr. Satel criticizes the manual for failing to divide the diagnoses "as tidily as the manual implies,"  because, for example, the same patient might suffer from bipolar disorder and ADHD. Perhaps she would have us give up. Just call them all crazy and lock them away. Why might someone not have 2 or more psychiatric disorders? You can have fleas AND lice.

So Dr. Satel, we might take a few steps back, but DSM-V will very likely move us forward at least a little.

DSM-5: Initial Impressions Positive

After a quick look I see nothing I do not like:

Substance Use Disorders:

Substance "abuse" always had too much of a moral connotation: Bad people abuse things. Having a substance use disorder does not make you bad.

Substance "Dependence" should have been Addiction all along. We usually mean physiological dependence as distinct from addiction.

Getting rid of both Abuse and Dependence is good.

Speaking of addiction, I'm glad "internet addiction" was NOT included as a behavioral addiction. For one thing, internet is not a behavior. Gambling is a behavior, but I'm glad they don't classify it as an addiction either.  More later.

Asperger's: Colorful as they are, naming diseases after people has no descriptive value, and if there's no bright line between Asperger's and the rest of the autism spectrum, so much the better. Good riddance.

Substituting "Intellectual Disability" for "Mental Retardation": We should probably incorporate "developmental" to distinguish from dementias, but even a small step toward ridding our language of the derogatory "retard" is good.