Debating DSM-5: diagnosis and the sociology of critique

By Martyn Pickersgill
Journal of Medical Ethics
J Med Ethics doi:10.1136/medethics-2013-101762

Abstract

The development of the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders—the DSM-5—has reenergised and driven further forward critical discourse about the place and role of diagnosis in mental health. The DSM-5 has attracted considerable criticism, not least about its role in processes of medicalisation. This paper suggests the need for a sociology of psychiatric critique. Sociological analysis can help map fields of contention, and cast fresh light on the assumptions and nuances of debate around the DSM-5; it underscores the importance of diagnosis to the governance of social and clinical life, as well as the wider discourses critical commentaries connect with and are activated by. More normatively, a sociology of critique can indicate which interests and values are structuring the dialogues being articulated, and just how diverse clinical opinion regarding the DSM can actually be. This has implications for the considerations of health services and policy decision-makers who might look to such debates for guidance.

The entire article is here.

Connecticut Mental Health Lawsuit Takes Insurers To Task

High Co-pays and issue in High Profile Case

By JAY STAPLETON
Connecticut Law Tribune
Originally published July 12, 2013

A Connecticut law firm has taken the lead in a high-profile federal lawsuit that accuses a group of insurance companies of overcharging for mental health services, prompting thousands of vulnerable patients to avoid treatment.

In the American Psychiatric Association v. Anthem Health Plans lawsuit, the firm of Murtha Cullina was hired as chief legal counsel for the plaintiffs. Attorney Marie Pepe VanDerLaan of the firm's Hartford office, the lead lawyer in the case, filed the complaint on the APA's behalf in U.S. District Court in New Haven.

At the heart of the claim is that the insurance company manipulated billing statements in order to charge higher co-pays for patients being treated for mental disorders than those required for patients with physical ailments. The APA is a lead plaintiff in the case, joined by psychologist Susan Savulak of Newington and several of her patients.

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.

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?

Treatment of Gender Identity Disorder: Guidelines from the ApA

by Mary Elizabeth Dallas
MedicineNet.com
Originally published on July 6, 2012

Psychiatrists who see transgender patients need specific guidelines to help determine the best course of treatment, according to new report from the American Psychiatric Association.

The American Psychiatric Association Task Force on Treatment of Gender Identity Disorder also calls for the psychiatrists' group to clarify its position on the health care and civil rights of people who are transgender or transitioning gender, meaning they are in the process of changing their gender through hormones and surgery.

The entire story is here.

The guidelines from the American Psychiatric Association are 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.

Autism Criteria Critics Blasted by DSM-5 Leader

By John Gever, Senior Editor
MedPage Today
Origianlly Published May 8, 2012

The head of the American Psychiatric Association committee rewriting the diagnostic criteria for autism spectrum disorders took on the panel's critics here, accusing them of bad science.

Susan Swedo, MD, of the National Institute of Mental Health, said a review released earlier this year by Yale University researchers was seriously flawed. That review triggered a wave of headlines indicating that large numbers of autism spectrum patients could lose their diagnoses and hence access to services.

Swedo spoke at the American Psychiatric Association's (APA) annual meeting, in her role as chairperson of the work group developing new diagnostic criteria for neurodevelopmental disorders in DSM-5, the forthcoming fifth edition of the APA's Diagnostic and Statistical Manual of Mental Disorders.

She was especially incensed by reports in consumer media about the Yale group's study, led by a New York Times article with a "blaring" headline that read, "New Definition of Autism May Exclude Many, Study Suggests." The Yale study, according to the Times article, found that most patients with Asperger's syndrome and about 25% of those with overt autism would not qualify for those diagnoses under DSM-5.

The entire story is here.

A Comparison of DSM-IV and DSM-5 Panel Members' Financial Associations with Industry: A Pernicious Problem Persists

By Krimsky Cosgronve

PLoS Medicine

All medical subspecialties have been subject to increased scrutiny about the ways by which their financial associations with industry, such as pharmaceutical companies, may influence, or give the appearance of influencing, recommendations in review articles, and clinical practice guidelines. Psychiatry has been at the epicenter of these concerns, in part because of high-profile cases involving ghostwriting, and failure to report industry-related income, and studies highlighting conflicts of interest in promoting psychotropic drugs. The revised 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. Some have questioned whether the inclusion of new disorders (e.g., Attenuated Psychotic Risk Syndrome) and widening of the boundaries of current disorders (e.g., Adjustment Disorder Related to Bereavement) reflects corporate interests. These concerns have been raised because the nomenclature, criteria, and standardization of psychiatric disorders codified in the DSM have a large public impact in a diverse set of areas ranging from insurance claims to jurisprudence. Moreover, through its relationship to the International Classification of Diseases, the system used for classification by many countries around the world, the DSM has a global reach.

After receiving criticism that DSM-IV had no financial disclosure of panel members, to its credit the APA instituted a mandatory disclosure policy. The DSM-5 panel members are required to file financial disclosure statements, which are expected to be listed in the publication, and the APA has made a commitment to improve its management of financial conflicts of interest (FCOIs).

The entire story is here.

DSM 5 Against Everyone Else

By Allen Frances, M.D.

Psychology Today Blog

Allen Frances, MD

So far, opposition to DSM 5 has been expressed by the following organizations: British Psychological Society; American Counseling Association; Society for Humanistic Psychology (APA Division 32); Society for Community Research and Action: Division of Community Psychology (APA Division 27); Society for Group Psychology & Psychotherapy (APA Division 49); Developmental Psychology (APA Division 7); UK Council for Psychotherapy; Association for Women in Psychology; Constructivist Psychology Network; Society for Descriptive Psychology; and the Society of Indian Psychologists.

An editorial by the Society Of Biological Psychiatry wondered whether DSM 5 was necessary at all. The community of personality disorders researchers is virtually unanimous in its opposition to the DSM 5 personality disorders section. There has also been widespread opposition to the sections on somatic, autistic, gender, paraphilic, and psychotic disorders.

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Strikingly, there seems to be virtually no support for DSM 5 outside the very narrow circle of the several hundred experts who have created it and the leadership of the American Psychiatric Association (APA) which stands to reap large profits from its publication. There is no group and precious few individuals outside of APA who have anything good to say about DSM 5. And even within the DSM 5 work groups and the APA governance structures, there is widespread discontent with the process and considerable disagreement about the product.

The entire blog can be accessed here.

Amicus Curiae Brief on Forced Medication of Loughner

ARLINGTON, Va. (Aug 4, 2011) - The American Psychiatric Association (APA) and the American Academy of Psychiatry and the Law (AAPL) have submitted an amicus curiae brief on the issue of forcibly administering antipsychotic medication in the case of the United States v. Jared Lee Loughner.

The brief was submitted August 3 to the U.S. Court of Appeals for the Ninth Circuit.

Loughner has pleaded not guilty in the Tucson, Arizona shootings that killed 6 people and injured 13 others, including Rep. Gabrielle Giffords.

He has been diagnosed with schizophrenia, was found incompetent to stand trial and is being held in a federal prison hospital in Springfield, Mo.

The APA/AAPL brief argues that under existing standards the government may administer involuntary medication to a pre-trial detainee who is a danger to himself or others if appropriate administrative procedures are followed.

It was also argued that such decisions should be made by those having custody of the defendant and should not require a judicial hearing.

"We have two interests in this case," said Paul S. Appelbaum, M.D., chair of APA's Committee on Judicial Action.

"When the courts address issues concerning psychiatric disorders, we want them to have accurate data on the nature and consequences of those illnesses and on appropriate treatments.

In addition, we believe psychiatrists working in correctional facilities need the flexibility to deal with dangerous persons without the delay involved in lengthy court proceedings. Those are the issues that we focus on in the brief."

The defense in the Tucson shootings case has opposed the defendant's being treated with antipsychotic medication, and the 9 th Circuit Court of Appeals halted further treatment with antipsychotics until a hearing before that court at the end of August.

Since then, the psychiatrists treating Loughner concluded he was rapidly deteriorating and represented a danger to himself, and antipsychotic medication was restarted on an emergency basis.

The brief submitted by APA and AAPL did not side with either party, but seeks to clarify issues regarding managing violent, including self-injurious, inmates and about the use of antipsychotic medications.

The brief addresses the scientific evidence of the benefits and risks associated with antipsychotic medications, likely side effects, the medical reasons for involuntary administration in certain circumstances, and the inappropriateness of using other medications (i.e., sedatives) in the place of antipsychotics.

In Loughner's appeal the court will address whether, in a case involving a pre-trial detainee, the Washington v. Harper standard may be applied in a prison administrative process or whether the greater protection of a judicial proceeding is required.

Washington v. Harper holds that the government may treat a prison inmate who has a serious mental illness with antipsychotic drugs against his will if he is dangerous to himself or others and if the treatment is in his medical interest.

In that case - which involved a convicted prisoner - the court also held that an administrative hearing was adequate to satisfy procedural due process.

Loughner's lawyers have raised additional substantive and procedural arguments.

The APA's position in the brief, approved by the APA Board of Trustees, is consistent with the organization's ongoing support of adequate mental health care for individuals in the criminal justice system.

Please see our prior blog post that details a history of this case.

Thanks to Ken Pope for this information.