Psychiatric diagnosis: the indispensability of ambivalence

By Felicity Callard
J Med Ethics doi:10.1136/medethics-2013-101763

Abstract

The author analyses how debate over the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders has tended to privilege certain conceptions of psychiatric diagnosis over others, as well as to polarise positions regarding psychiatric diagnosis. The article aims to muddy the black and white tenor of many discussions regarding psychiatric diagnosis by moving away from the preoccupation with diagnosis as classification and refocusing attention on diagnosis as a temporally and spatially complex, as well as highly mediated process. The article draws on historical, sociological and first-person perspectives regarding psychiatric diagnosis in order to emphasise the conceptual—and potentially ethical—benefits of ambivalence vis-à-vis the achievements and problems of psychiatric diagnosis.

The entire article is here.

The DSM-5: A Vehicle For High-Profit Patent Extensions?

Gregg Fields & Lisa Cosgrove | Labcast
Harvard University SoundCloud Podcast

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders affects drugs with sales in the billions of dollars. In research supported by the Edmond J. Safra Center for Ethics, Lisa Cosgrove of UMass-Boston investigated financial ties between DSM panel members and the pharmaceutical companies that have a vested interest in finding new indications for their blockbuster drugs. In this podcast, she tells journalist Gregg Fields what she found, what it means—and why we all should care.

"Tripartite Conflicts of Interest and High Stakes Patent Extensions in the DSM-5," Psychotherapy and Psychosomatics.

A proposal to classify happiness as a psychiatric disorder

By Richard P Bentall
Journal of medical ethics, 1992, 18, 94-98

Abstract

It is proposed that happiness be classified as a psychiatric disorder and be included in future editions of the major diagnostic manuals under the new name: major affective disorder, pleasant type. In a review of the relevant literature it is shown that happiness is statistically abnormal, consists of a discrete cluster of symptoms, is associated with a range of cognitive abnormalities, and probably reflects the abnormal functioning of the central nervous system. One possible objection to this proposal remains - that happiness is not negatively valued.  However, this objection is dismissed as scientifically irrelevant.

The entire article is here.

New Mental-Health Manual Likely to Impact HR

Making accommodations for employees with mental disabilities has never been easy, and it's about to get more difficult with the release of the American Psychiatric Association's new manual of mental disorders.

By James J. McDonald, Jr.
Human Resource Executive Online
Originally published May 22, 2013

In psychiatry, unlike other branches of medicine, there is no laboratory test that can confirm the existence of a particular mental disorder. Psychiatrists and other mental health professionals rely on the Diagnostic and Statistical Manual of Mental Disorders, known as "DSM-5" to diagnose patients. The American Psychiatric Association has just released a new fifth edition of the manual and human resources executives should take note. It contains new diagnostic categories not listed in its predecessor and loosens the criteria for some diagnoses which will likely result in more people qualifying for these diagnoses. DSM-5 is likely to impact HR by expanding the number of employees who will qualify as disabled under the Americans with Disabilities Act and be entitled to reasonable accommodation.

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New Diagnoses

DSM-5 adds several new diagnoses that employers are likely to find vexing. One is "Social (Pragmatic) Communication Disorder," which describes persons whose communication skills are impaired but who do not qualify for an autism diagnosis. It applies to persons with "persistent difficulties in the social use of verbal and nonverbal communications" that limit social relationships or occupational performance. While typically diagnosed in childhood it can continue into adulthood. Employees previously thought to be merely shy or socially awkward may qualify for this new diagnosis.

Another new diagnosis is "Binge Eating Disorder," a condition characterized primarily by eating a large amount of food in a short time at least once per week for three months. DSM-5 notes that while most overweight persons do not engage in recurrent binge-eating, Binge Eating Disorder is "reliably associated with overweight and obesity."  Thus, this diagnosis makes it more likely that obesity (at least when precipitated by binge-eating) might finally qualify as a disability under the ADA.

The entire article is here.

Doctors Protest Psychiatric Manual Revision in Global Petition

By Natasha Khan
Bloomberg News
May 15, 2013

Doctors are protesting new guidance for the diagnosis of some mental disorders, including autism, contained in the revised edition of a professional manual to be released in coming days.

The so-called “psychiatric bible,” whose first update in 19 years will be released at a medical meeting that opens in San Francisco on May 18, also influences the way patients are treated and reimbursed for mental disorders. A petition that raised concerns about the manual’s diagnostic categories and patient safety received more than 3,000 signatures from Paris to Montreal in recent months.

The Diagnostic and Statistical Manual of Mental Disorders is the standard used by mental-health professionals for diagnosing illness and for research. The newest edition is meant to incorporate the latest research findings and has collapsed several conditions, including Asperger’s syndrome and child disintegrative disorder, into a single autism diagnosis.

The entire article is here.

Medicine's big new battleground: does mental illness really exist?

The latest edition of DSM, the influential American dictionary of psychiatry, says that shyness in children, depression after bereavement, even internet addiction can be classified as mental disorders. It has provoked a professional backlash, with some questioning the alleged role of vested interests in diagnosis

By Jaime Doward
The Observer
Originally published May 11, 2013

It has the distinctly uncatchy, abbreviated title DSM-5, and is known to no one outside the world of mental health.

But, even before its publication a week on Wednesday, the fifth edition of the Diagnostic and Statistical Manual, psychiatry's dictionary of disorders, has triggered a bitter row that stretches across the Atlantic and has fuelled a profound debate about how modern society should treat mental disturbance.

Critics claim that the American Psychiatric Association's increasingly voluminous manual will see millions of people unnecessarily categorised as having psychiatric disorders. For example, shyness in children, temper tantrums and depression following the death of a loved one could become medical problems, treatable with drugs. So could internet addiction.

Inevitably such claims have given ammunition to psychiatry's critics, who believe that many of the conditions are simply inventions dreamed up for the benefit of pharmaceutical giants.

A disturbing picture emerges of mutual vested interests, of a psychiatric industry in cahoots with big pharma. As the writer, Jon Ronson, only half-joked in a recent TED talk: "Is it possible that the psychiatric profession has a strong desire to label things that are essential human behaviour as a disorder?"

Psychiatry's supporters retort that such suggestions are clumsy, misguided and unhelpful, and complain that the much-hyped publication of the manual has become an excuse to reheat tired arguments to attack their profession.

The entire article is here.

DSM-IV Boss Presses Attack on New Revision

By John Gever, Deputy Managing Editor
MedPage Today
Published: May 17, 2013

A new edition of psychiatry's diagnostic guide "will probably lead to substantial false-positive rates and unnecessary treatment," charged the man who led development of the last version.

To be released this weekend at the American Psychiatric Association's annual meeting, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, "introduce[s] several high-prevalence diagnoses at the fuzzy boundary with normality," according to Allen Frances, MD, who chaired the task force responsible for DSM-IV issued in 1994.

Frances, now an emeritus professor at Duke University, wrote online in Annals of Internal Medicine that changes from DSM-IV will apply disease labels to individuals who may be unhappy or offensive but still normal. Such individuals would include those experiencing "the forgetfulness of old age" as well as children with severe, chronic temper tantrums and individuals with physical symptoms with no medical explanation.

He also worried about new marketing pushes from the pharmaceutical industry seeking to exploit what he believes are "loose" diagnostic criteria in the new edition. "Drug companies take marketing advantage of the loose DSM definitions by promoting the misleading idea that everyday life problems are actually undiagnosed psychiatric illness caused by a chemical imbalance and requiring a solution in pill form," he wrote.

The entire article is here.

New Efforts to Overhaul Psychiatric Diagnoses Spurred by DSM Turmoil

By Greg Miller
Wired Science
Originally posted May 17, 2013

Thousands of psychiatrists will descend on San Francisco this weekend for a meeting that will mark the release of the latest edition of the profession’s diagnostic guide, the Diagnostic and Statistical Manual of Mental Disorders, or DSM for short. This hugely influential book has been 14 years in the making, and it’s been dogged by controversies every step of the way.

To name just a few, there have been allegations of financial conflicts of interest, debates over whether internet addiction is really a thing (it is not, but “disordered gambling” is), arguments that the new diagnostic criteria will medicalize normal grief and temper tantrums, and lead to millions of people being falsely diagnosed with mental disorders.

With the new manual on the eve of its official debut, many experts are already looking beyond it. Some envision a future in which psychiatric diagnoses are based on the underlying biological causes instead of a description of a patient’s symptoms. Others caution that such a single-minded focus on biology ignores important social factors that contribute to mental illness. If there’s any area of agreement it’s this: There has to be a better way.


The DSM is used by doctors to diagnose patients, by insurance companies to decide what treatments to pay for, and by pharmaceutical companies and government funding agencies to set research priorities. The new edition, DSM-5, defines hundreds of mental disorders.

The fundamental problem, according to many of DSM’s critics, is that these definitions don’t carve nature at its joints.

“An obvious, easy example is schizophrenia,” said Peter Kinderman, a clinical psychologist at the University of Liverpool. “If you’re a 52-year-old man who hears voices, you’ll receive a diagnosis of schizophrenia. If you’re a 27-year-old woman with delusional beliefs, you’ll also receive a diagnosis of schizophrenia,” Kinderman said. “Two people can receive the same diagnosis and not have a single thing in common. That’s ludicrous scientifically.”

In most areas of medicine, diagnoses are based on the cause of illness. Heartburn and heart attacks both cause chest pain, but they’re different diagnoses because they have different underlying causes.

The entire story is here.

Psychiatry’s Guide Is Out of Touch With Science, Experts Say

By PAM BELLUCK and BENEDICT CAREY
The New York Times
Published: May 6, 2013

Just weeks before the long-awaited publication of a new edition of the so-called bible of mental disorders, the federal government’s most prominent psychiatric expert has said the book suffers from a scientific “lack of validity.”

The expert, Dr. Thomas R. Insel, director of the National Institute of Mental Health, said in an interview Monday that his goal was to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.

While the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., is the best tool now available for clinicians treating patients and should not be tossed out, he said, it does not reflect the complexity of many disorders, and its way of categorizing mental illnesses should not guide research.

“As long as the research community takes the D.S.M. to be a bible, we’ll never make progress,” Dr. Insel said, adding, “People think that everything has to match D.S.M. criteria, but you know what? Biology never read that book.”

The entire story is here.

Why the Fuss Over the D.S.M.-5?

By Sally Satel
The New York Times - Opinion
Originally published on May 11, 2013

LATER this month, the American Psychiatric Association will unveil the fifth edition of its handbook of diagnoses, the Diagnostic and Statistical Manual of Mental Disorders. Fourteen years in the making, the D.S.M.-5 has been the subject of seemingly endless discussion.
      

The charges are familiar: the manual medicalizes garden-variety distress, leads doctors to prescribe unnecessary medications, serves as a cash cow for the association, and so forth.

      

But many critics overlook a surprising fact about the new D.S.M.: how little attention practicing psychiatrists will give to it.

      

There are dozens of revisions in the D.S.M. — among them, the elimination of a “bereavement exclusion” from major depressive disorder and the creation of binge eating disorder — but they won’t alter clinical practice much, if at all.

      

This is because psychiatrists tend to treat according to symptoms.

      

So why the fuss over D.S.M.-5? Because of the unwarranted clout that its diagnoses carry with the rest of society: They are the passports to insurance coverage, the keys to special educational and behavioral services in school and the tickets to disability benefits.

      

This is a problem because the D.S.M. is an imperfect guide to predicting what treatments will benefit patients most — a reality tied to the fact that psychiatric diagnoses are based on clinical appearances that tend to cluster, not on the mechanism behind the illness, as is the case with, say, bacterial pneumonia.

The entire article is here.

Transforming Diagnosis

By Thomas Insel on April 29, 2013
NIMH Director’s Blog

In a few weeks, the American Psychiatric Association will release its new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This volume will tweak several current diagnostic categories, from autism spectrum disorders to mood disorders. While many of these changes have been contentious, the final product involves mostly modest alterations of the previous edition, based on new insights emerging from research since 1990 when DSM-IV was published. Sometimes this research recommended new categories (e.g., mood dysregulation disorder) or that previous categories could be dropped (e.g., Asperger’s syndrome).

The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

Patients with mental disorders deserve better. NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.

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That is why NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system.

The entire blog post is here.

Editorial note: The NIMH will no longer use DSM-5 diagnostic criteria.  There have also been numerous criticisms related to DSM-5.  And, given that HIPAA requires ICD diagnostic codes for billing, is there a reason for psychologists to purchase a DSM-5?

Ethical and practical implications of financial conflicts of interest in the DSM-5

By Lisa Cosgrove and Emily Wheeler
doi: 10.1177/0959353512467972
Feminism Psychology
February 2013 vol. 23 no. 1 93-106

Abstract

The revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), scheduled for publication in May 2013 by the American Psychiatric Association (APA), has created a firestorm of controversy because of questions about undue industry influence. Specifically, concerns have been raised about financial conflicts of interest between DSM-5 panel members and the pharmaceutical industry. The authors argue that current approaches to the management of these relationships, particularly transparency of them, are insufficient solutions to the problem of industry’s capture of organized psychiatry. The conceptual framework of institutional corruption is used to understand psychiatry’s dependence on the pharmaceutical industry and to identify the epistemic assumptions that ground the DSM’s biopsychiatric discourse. APA’s rationale for including premenstrual dysphoric disorder in the DSM-5 as a Mood Disorder is reviewed and discussed.

Thanks to Ken Pope for sharing this abstract.

Mislabeling Medical Illness

By ALLEN FRANCES, MD
The Health Care Blog
Originally published on February 12, 2013


Many readers of my previous blog listing the 10 worst suggestions in DSM 5 were shocked that I failed to mention an 11th dangerous mistake — that DSM-5 will harm people who are medically ill by mislabeling their medical problems as mental disorder. They are absolutely right. I apologize for my previous failure to attend to this danger and hope it is not now too late to influence the process.

Adding to the woes of the medically ill could be one of the biggest problems caused by DSM-5. It will do this in two ways: 1) by encouraging a quick jump to the erroneous conclusion that someone’s physical symptoms are ‘all in the head’; and 2) by mislabeling as mental disorders what are really just the normal emotional reactions that people understandably have in response to a medical illness.

UK health advocate, Suzy Chapman, has closely monitored every step in the development of DSM-5. Her website is the best available resource for finding just about everything you need to know about DSM-5 and ICD-11. Ms Chapman sent me a troubling email that summarizes where DSM-5 has gone wrong and the many harmful consequences that will follow. More details are available at: ‘Somatic Symptom Disorder could capture millions more under mental health diagnosis’ (http://wp.me/pKrrB-29B )

Ms Chapman writes:

…The DSM-5 Somatic Symptom Disorders Work Group is planning to eliminate several little used DSM-IV Somatoform Disorders and replace them instead with an extremely broad new category that is likely to be wildly overused (‘Somatic Symptom Disorder’ — SSD).

A person will meet the criteria for SSD by reporting just one bodily symptom that is distressing and/or disruptive to daily life and having just one of the following three reactions to it that persist for at least six months: 1) ‘disproportionate’ thoughts about the seriousness of their symptom(s); or 2) a high level of anxiety about their health; or, 3) devoting excessive time and energy to symptoms or health concerns.

The entire blog post is here.

Grief Over New Depression Diagnosis

By Paula Span
The New York Time Blog - The New Old Age
Originally published January 24, 2013

When the American Psychiatric Association unveils a proposed new version of its Diagnostic and Statistical Manual of Mental Disorders, the bible of psychiatric diagnoses, it expects controversy. Illnesses get added or deleted, acquire new definitions or lists of symptoms. Everyone from advocacy groups to insurance companies to litigators — all have an interest in what’s defined as mental illness — pays close attention. Invariably, complaints ensue.

“We asked for commentary,” said David Kupfer, the University of Pittsburgh psychiatrist who has spent six years as chairman of the task force that is updating the handbook. He sounded unruffled. “We asked for it and we got it. This was not going to be done in a dark room somewhere.”

But the D.S.M. 5, to be published in May, has generated an unusual amount of heat. Two changes, in particular, could have considerable impact on older people and their families.

First, the new volume revises some of the criteria for major depressive disorder. The D.S.M. IV (among other changes, the new manual swaps Roman numerals for Arabic ones) set out a list of symptoms that over a two-week period would trigger a diagnosis of major depression: either feelings of sadness or emptiness, or a loss of interest or pleasure in most daily activities, plus sleep disturbances, weight loss, fatigue, distraction or other problems, to the extent that they impair someone’s functioning.

The entire blog post is here.

Proposed DSM-5 Changes To Assessment Of Alcohol Problems

Medical News Today
Originally posted January 24, 2013

Proposed changes to the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) will affect the criteria used to assess alcohol problems. One change would collapse the two diagnoses of alcohol abuse (AA) and alcohol dependence (AD) into a single diagnosis called alcohol use disorder (AUD). A second change would remove "legal problems," and a third would add a criterion of "craving." A study of the potential consequences of these changes has found they are unlikely to significantly change the prevalence of diagnoses.

Results will be published in the March 2013 issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.

"Updating the DSM could be advantageous if changes are made based on improvements in our understanding of a disorder's etiology, and/or if changes improve the accuracy of the diagnosis," said Alexis C. Edwards, assistant professor in the Department of Psychiatry at Virginia Commonwealth University School of Medicine as well as corresponding author for the study. "It would probably be a little disappointing if no changes were ever made, because that might suggest that we haven't made much headway in understanding and accurately diagnosing psychiatric disorders, despite all our efforts."

The entire story is here.

DSM-5 Could Be Hazardous to Your Mental Health

By Elayne Clift
OpEdNews.com
Originally published on December 22, 2012

Here are some excerpts:

Feminist therapists are concerned for women in particular. Diagnoses such as Borderline Personality Disorder (BPD) and Sexual Dysfunction have disparaged women and compromised them in troubling ways. For example, one expert says that BPD is almost exclusively applied to women because its symptoms relate to emotion and anger.   Some women with the diagnosis have histories of abuse and may have difficulty expressing anger "appropriately."   Such vulnerable women need to have their coping styles better understood before assumptions are made about their behavior.

Similarly, "sexual dysfunction" among women is often based on assumptions about what constitutes normal sexual behavior.   "If only performance failures or lack of desire count, the entire context of sexual activity becomes invisible and of secondary importance," says one member of the Association of Women in Psychology (AWP).

Another AWP member focuses on classism in psychiatric diagnosis.   "Poor women and women of color are particularly likely to be misdiagnosed or encounter bias in treatment," she says. "Therapists may interpret chronic lateness or missed appointments as hostility or resistance to treatment rather than the outcomes of unreliable transportation, irregular shift work, and unpredictable child care arrangements."

The entire article is here.

UConn Researchers Voice Concern Over Proposed Addiction Guideline Changes

By Lisa Catanese
UCONN Today
Originally published June 2, 2012

Two prominent University of Connecticut Health Center researchers are adding their voices to a chorus of other national experts who are questioning proposed changes regarding substance abuse guidelines in a manual used internationally in the diagnosis and treatment of mental illnesses.

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Babor’s reservations about the proposed changes concern the broadening of language defining addiction and the lowering of the threshold of what counts as a substance use disorder. The revisions would expand the number of symptoms of addiction, reduce the number required for a diagnosis, and introduce a “behavioral addiction” category – all of which could lead to millions more people being categorized as addicts when they in fact are simply unhealthy users. This could put a strain on already-limited resources in schools, prisons, and hospitals, he says.

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Kaminer is concerned about the impact of the proposed DSM changes from two perspectives – classifying too many people as having a problem while deterring adolescents from seeking treatment. “There are not enough resources right now,” he says. “This country is collapsing under the burden of health care. Is it necessary to expand diagnosis to include mild cases and yet push away prospective clients by calling them addicts?”

The entire story is here.

The D.S.M. Gets Addiction Right

By Howard Markel
The New York Times - Opinion
Orignally published June 5, 2012

WHEN we say that someone is “addicted” to a behavior like gambling or eating or playing video games, what does that mean? Are such compulsions really akin to dependencies like drug and alcohol addiction — or is that just loose talk?

This question arose recently after the committee writing the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (D.S.M.), the standard reference work for psychiatric illnesses, announced updated definitions of substance abuse and addiction, including a new category of “behavioral addictions.” At the moment, the only disorder featured in this new category is pathological gambling, but the suggestion is that other behavioral disorders will be added in due course. Internet addiction, for instance, was initially considered for inclusion but was relegated to an appendix (as was sex addiction) pending further research.

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Disease definitions change over time because of new scientific evidence. This is what has happened with addiction. We should embrace the new D.S.M. criteria and attack all the substances and behaviors that inspire addiction with effective therapies and support.

The entire opinion is here.

Diagnosing the D.S.M.

By Allen Frances
The New York Times - Opinion
Originally published May 11, 2012

At its annual meeting this week, the American Psychiatric Association did two wonderful things: it rejected one reckless proposal that would have exposed nonpsychotic children to unnecessary and dangerous antipsychotic medication and another that would have turned the existential worries and sadness of everyday life into an alleged mental disorder.

But the association is still proceeding with other suggestions that could potentially expand the boundaries of psychiatry to define as mentally ill tens of millions of people now considered normal. The proposals are part of a major undertaking: revisions to what is often called the “bible of psychiatry” — the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M. The fifth edition of the manual is scheduled for publication next May.

I was heavily involved in the third and fourth editions of the manual but have reluctantly concluded that the association should lose its nearly century-old monopoly on defining mental illness. Times have changed, the role of psychiatric diagnosis has changed, and the association has changed. It is no longer capable of being sole fiduciary of a task that has become so consequential to public health and public policy.

The entire story is here.

Psychiatry Manual Drafters Back Down on Diagnoses

By Benedict Carey
The New York Times - Health
Originally published May 8, 2012

In a rare step, doctors on a panel revising psychiatry’s influential diagnostic manual have backed away from two controversial proposals that would have expanded the number of people identified as having psychotic or depressive disorders.

The doctors dropped two diagnoses that they ultimately concluded were not supported by the evidence: “attenuated psychosis syndrome,” proposed to identify people at risk of developing psychosis, and “mixed anxiety depressive disorder,” a hybrid of the two mood problems.

They also tweaked their proposed definition of depression to allay fears that the normal sadness people experience after the loss of a loved one, a job or a marriage would not be mistaken for a mental disorder.

But the panel, appointed by the American Psychiatric Association to complete the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., did not retreat from another widely criticized proposal, to streamline the definition of autism.

The entire story is here.