Wednesday, July 8, 2009

The Battle over the DSM V

As some of you may know, the diagnostic and statistical manual of mental disorders (DSM) is up for some big revisions, and the DSM-V is set to come out in 2012. This seems like a ways away but committees are already well underway deciding what should be included in the new version, what should be taken out, and what should be transformed. A little background: DSM changes are decided by the creation of what the APA calls "committees", which are basically groups of researchers and leading experts in their fields (such as experts in depression, schizophrenia, PTSD, etc). These committees meet regurlary to decide upon changes to diagnostic criteria after careful review of the literature and much debate with each other. That being said, there is more battle and public denouncement of the new methods being used in the consideration of changes to the DSM than ever before. One of the problems seems to be the APA's complete secrecy as to what is being considered for the DSM-V. The DSM is created by the American Psychiatric Association and not the American Psychological Association, so keep this in mind. Recently Allen Frances, head of the DSM-IV task force has published what he titles : A Warning Sign on the Road to the DSM, a very poignant look at what the APA is doing wrong. His main argument is that the DSM V is being rushed to completion without adequate scientific basis and the APA's need to completely revolutionize the DSM by adding dimmensions of mental illness rather than categories is premature at best (since we don't yet have enough research or evidence to go about this in an organized fashion). Of the changes, Frances says:

The result would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments‐‐a bonanza for the pharmaceutical industry but at a huge cost to the new false positive "patients" caught in the excessively wide DSM‐V net. They will pay a high price in side effects, dollars, and stigma, not to

mentions the unpredictable impact on insurability, disability, and forensics.

Another proposed change to the DSM is the formation of what I call pre-mental illness diagnoses, that is to say. a DSM that could catch someone who is likely to develop, say schizophrenia, and treat them early. Of this, Frances states:

This again has the obvious appeal of promoting early case finding and preventive treatment, but it also has all the same devastating problems we have just discussed. For example, adding a new "pre‐psychotic" category for individuals supposedly at high risk for later developing a psychotic disorder would inevitably also capture an overwhelmingly large group of false positives who would never go on to have a psychotic illness. They would nonetheless be exposed to the stigma of having a pre‐psychotic diagnosis and would be overmedicated. Similarly, wouldn't it be nice to diagnose and treat early cognitive failure before it becomes dementia? But then almost everyone over sixty might qualify to receive a

probably useless, but highly promoted treatment.

The problem, I think, is that in theory these changes sound good. Dimmensional categories of mental illness, rather than straight checkboxes take into account that mental illness is by its nature multidimmensional and that way may work for one person as a method of treatment might not work for another. However, we are not there yet in terms of research to reconfigure the DSM in this way. I do think we would end up with a lot more people meeting the diagnosis of say depression. And here is where the corruption comes in. The DSM, funded by the American Psychiatric Association, has always used the medical model, which treats mental illness as a disease that can be treated, for the most part, with drugs. It is no unkown secret that many members of the APA, as well as members of the DSM task force (who need money to conduct their research), receive their funding from large pharmaceutical industries. It doesn't take a genius to see why the APA is so readily accepting this new multidimmensional model and these "pre-mental illness's" into the DSM, as they would include a much larger demographic of people, all of whom would need drugs.

Recently Dr. Jane Costello, an expert in the development of mental illness, has also quit her post on the DSM V task force, citing again a rush to completion and a dismissal of scientific evidence. The Carlat Psychiatry Blog covers this story well.

It makes me very outraged, and also very sad, that a system that is so widely used in the United States, and is also the base of deciding mental illness in many other countries, is open to such corruption.

I will keep you updated as the battle, I'm sure, continues.

1 comment:

  1. Hi Jos, the blog looks great. Que tengas mucha suerte con la escritura - Vaughan