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.

Is ADHD diagnosed in accord with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis.

By Katrin Bruchmuller, Jurgen Margraf, and Silvia Schneider

Journal of Consulting and Clinical Psychology, Vol 80(1), Feb 2012, 128-138.

 

Abstract

 

Objective: Unresolved questions exist concerning diagnosis of ADHD. First, some studies suggest a potential overdiagnosis. Second, compared with the male–female ratio in the general population (3:1), many more boys receive ADHD treatment compared with girls (6–9:1). We hypothesized that this occurs because therapists do not adhere to Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–IV) and International Classification of Diseases (10th rev.; ICD–10) criteria. Instead, we hypothesized that, in accordance with the representativeness heuristic, therapists might diagnose attention-deficit/hyperactivity disorder (ADHD) if a patient resembles their concept of a prototypical ADHD child, leading therapists to overlook certain exclusion criteria. This may result in overdiagnosis. Furthermore, as ADHD is more frequent in males, a boy might be seen as a more prototypical ADHD child and might therefore receive an ADHD diagnosis more readily than a girl would.

 

Method: We sent a case vignette to 1,000 child psychologists, psychiatrists, and social workers and asked them to give a diagnosis. Four versions of the vignette existed: Vignette 1 (ADHD) fulfilled all DSM–IV/ICD–10 criteria of ADHD. Vignettes 2–4 (non-ADHD) included several ADHD symptoms but stated other ADHD criteria were nonfulfilled. Therefore, an ADHD diagnosis could not be given. Furthermore, boy and girl versions of each vignette were created.

 

Results: In Vignettes 2–4 (non-ADHD), 16.7% of therapists diagnosed ADHD. In the boy version of these vignettes, therapists diagnosed ADHD around 2 times more than they did with the girl vignettes.

 

Conclusions: Therapists do not adhere strictly to diagnostic manuals. Our study suggests that overdiagnosis of ADHD occurs in clinical routine and that the patient's gender influences diagnosis considerably. Thorough diagnostic training might help therapists to avoid these biases.

My Third Letter to the APA Trustees

A Poor Quality DSM-5 in Unacceptable

By Allen Frances, MD

DSM-5 press coverage has suddenly exploded—more than 100 stories from all around the world were published in just the last three weeks (see title and links below). The press is uniformly negative and extremely damaging to DSM-5, to APA, and to the credibility of psychiatry.

The APA responses have been few, unconvincing, and lacking in substance. Also troubling, 47 mental health organizations have expressed their opposition to DSM-5 by endorsing a petition requesting it to have a scientific review independent of APA. And many users are planning to boycott DSM-5 altogether by substituting ICD-10-CM (which will be freely available on the internet). It is fair to say that DSM-5 has become an object of general public and professional scorn.

What would Mel Sabshin be doing in this time of crisis? Of course, Mel never would have allowed APA to get into this mess—but once in any crisis he was an expert in damage control. Were he here today, Mel would certainly recommend that you immediately cut the DSM-5 losses to prevent its inflicting further damage on APA, on psychiatry, and most importantly on our patients.

The entire blog entry is here.

DSM-5 Critics Pump Up the Volume

By John Gever, Senior Editor, MedPage Today

Published: February 29, 2012

With crunch time looming for the ongoing revision of the psychiatry profession's diagnostic manual, critics hoping to stop what they see as destructive changes are taking their campaign to the consumer media.

In early February, British psychologists and psychiatrists unhappy with proposed changes in the fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders -- the DSM-5, in its forthcoming incarnation -- staged a successful press conference in London, which generated news coverage around the world.

Meanwhile, the most prominent U.S.-based critic of DSM-5, Allen Frances, MD -- chairman of the task force that developed the fourth DSM edition in 1994 -- has become a regular contributor to the popular Huffington Post website. Last week, he suggested there that the government should force the APA to abandon some of the proposed changes.

And the explosion in social media has allowed other, less well-connected mental health professionals and interested laypeople to create their own platforms for airing concerns about DSM-5 -- starting websites and writing comments on others.

At least in part, the rising furor is driven by the DSM-5 revision schedule. The APA has committed to releasing the final version at its May 2013 meeting. Its internal process for ratifying it requires that it be in essentially final form this winter.

Thus, only a few months remain for critics to sway the DSM-5 leadership.

The entire story is here.

Calling for an End to Phony Military Discharges

Letter to the Editor

New York Times

Originally published March 3, 2012

To the Editor:

“Branding a Soldier With ‘Personality Disorder’ ” (front page, Feb. 25) scratched the surface of an important military scandal.

I have been investigating personality disorder discharges for the last six years. In that time, I’ve interviewed dozens of physically wounded soldiers who were booted from the military with a phony “pre-existing personality disorder,” which prevents the soldiers from receiving disability and medical benefits. They even have to give back a chunk of their signing bonus.

Soldiers severely wounded in combat are finding out on their final day in uniform that they will never get disability benefits — and they now owe the military thousands of dollars.

I have also interviewed military doctors about being pressed by their superiors to misdiagnose wounded soldiers. One doctor told me of a soldier who came back with a chunk missing from his leg. His superior pressured him to diagnose that injury as personality disorder.

The numbers in this scandal are staggering. Since 2001, the military has discharged more than 31,000 soldiers with personality disorder, at a savings to the military of over $17.2 billion in disability and medical benefits.

Barack Obama had been at the forefront of this issue. As a senator, he put forward a bill to halt all personality disorder discharges. But as commander in chief, he has done nothing to halt these fraudulent dismissals.

The American people should confront the president and the Republican presidential candidates with this question: As commander in chief, what actions will you take to keep these phony personality disorder discharges from devastating another military family?

JOSHUA KORS

New York, Feb. 26, 2012

The writer is a freelance reporter.

Not Diseases, but Categories of Suffering

By GARY GREENBERG

The New York Times - Opinion

Published: January 29, 2012

YOU’VE got to feel sorry for the American Psychiatric Association, at least for a moment. Its members proposed a change to the definition of autism in the fifth edition of their Diagnostic and Statistical Manual of Mental Disorders, one that would eliminate the separate category of Asperger syndrome in 2013. And the next thing they knew, a prominent psychiatrist was quoted in a front-page article in this paper saying the result would be fewer diagnoses, which would mean fewer troubled children eligible for services like special education and disability payments.

Then, just a few days later, another front-pager featured a pair of equally prominent experts explaining their smackdown of the A.P.A.’s proposal to eliminate the “bereavement exclusion” — the two months granted the grieving before their mourning can be classified as “major” depression. This time, the problem was that the move would raise the numbers of people with the diagnosis, increasing health care costs and the use of already pervasive mind-altering drugs, as well as pathologizing a normal life experience.

Fewer patients, more patients: the A.P.A. just can’t win. Someone is always mad at it for its diagnostic manual.

It’s not the current A.P.A.’s fault. The fault lies with its predecessors. The D.S.M. is the offspring of odd bedfellows: the medical industry, with its focus on germs and other biochemical causes of disease, and psychoanalysis, the now-largely-discredited discipline that attributes our psychological suffering to our individual and collective history.

The entire story is here.

I Had Asperger Syndrome. Briefly.

By Benjamin Nugent
The New York Times
The Opinion Pages
Originally Published January 31, 2012

FOR a brief, heady period in the history of autism spectrum diagnosis, in the late ’90s, I had Asperger syndrome.

There’s an educational video from that time, called “Understanding Asperger’s,” in which I appear. I am the affected 20-year-old in the wannabe-hipster vintage polo shirt talking about how keen his understanding of literature is and how misunderstood he was in fifth grade. The film was a research project directed by my mother, a psychology professor and Asperger specialist, and another expert in her department. It presents me as a young man living a full, meaningful life, despite his mental abnormality.

“Understanding Asperger’s” was no act of fraud. Both my mother and her colleague believed I met the diagnostic criteria laid out in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The manual, still the authoritative text for American therapists, hospitals and insurers, listed the symptoms exhibited by people with Asperger disorder, and, when I was 17, I was judged to fit the bill.

I exhibited a “qualified impairment in social interaction,” specifically “failure to develop peer relationships appropriate to developmental level” (I had few friends) and a “lack of spontaneous seeking to share enjoyment, interests, or achievements with other people” (I spent a lot of time by myself in my room reading novels and listening to music, and when I did hang out with other kids I often tried to speak like an E. M. Forster narrator, annoying them). I exhibited an “encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus” (I memorized poems and spent a lot of time playing the guitar and writing terrible poems and novels).

The general idea with a psychological diagnosis is that it applies when the tendencies involved inhibit a person’s ability to experience a happy, normal life. And in my case, the tendencies seemed to do just that. My high school G.P.A. would have been higher if I had been less intensely focused on books and music. If I had been well-rounded enough to attain basic competence at a few sports, I wouldn’t have provoked rage and contempt in other kids during gym and recess.

The thing is, after college I moved to New York City and became a writer and met some people who shared my obsessions, and I ditched the Forsterian narrator thing, and then I wasn’t that awkward or isolated anymore. According to the diagnostic manual, Asperger syndrome is “a continuous and lifelong disorder,” but my symptoms had vanished.

The entire story is here.

Dr. Robert Gordon's Comment on DSM

Recently, Dr. Robert Gordon posted a comment on the Pennsylvania Psychological Association's listserv about the upcoming DSM-5 revision.

I have been writing to the DSM 5 committee my suggestions and concerns. However, I do not like the DSM. I use a combination of the ICD and PDM. The DSM is American psychiatry's political motive to put mental health care under their umbrella.

As I commonly state in court, "The DSM is a product of a particular guild and it has no legal or scientific authority. My diagnostic opinion is based on the best available research."

 Yet, in over 100 years, the American Psychological Association has not been able to do better. We argue a lot among ourselves, but we have failed to produce a diagnostic system that is better than the DSM.

The international psychodynamic community produced the excellent Psychodynamic Diagnostic Manual (PDM 2006).

WHY A NEW DIAGNOSTIC MANUAL?

Robert Gordon, PhD ABPP

The Psychodynamic Diagnostic Manual (PDM Task Force, 2006) is the first psychological diagnostic classification system that considers the whole person in various stages of development. A task force of five major psychoanalytic organizations and leading researchers, under the guidance of Stanley I. Greenspan, Nancy McWilliams, and Robert Wallerstein came together to develop the PDM. The resulting nosology goes from the deep structural foundation of personality to the surface symptoms that include the integration of behavioral, emotional, cognitive, and social functioning.

The PDM improves on the existing diagnostic systems by considering the full range of mental functioning. In addition to culling years of psychoanalytic studies of etiology and pathogenesis, the PDM relies on research in neuroscience, treatment outcome, infant and child development, and personality assessment.

The PDM does not look at symptom patterns described in isolation, as do the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM). Research on brain development and the maturation of mental processes suggests that patterns of behavioral, emotional, cognitive, and social functioning involve many areas working together rather than in isolation. Although it is based on psychodynamic theory and supporting research, the PDM is not doctrinaire in its presentation. It may be used in conjunction with the ICD or DSM. The PDM Task Force made an effort to use language that is accessible to all the schools of psychology. It was developed to be particularly useful in case formulation that could improve the effectiveness of any psychological intervention.

The PDM has received very favorable reviews from mostly the psychoanalytic community (Clemens, 2007; Ekstrom, 2007; Migone, 2006; and Silvio, 2007).  However, even non-psychodynamic psychologists that were introduced to the PDM as part of MMPI-2 and ethics/risk management workshops had a positive reaction to the new diagnostic system.  Ninety percent of 192 psychologists surveyed (65 Psychodynamic, 76 CBT and 51 Family Systems, Humanistic/Existential, Eclectic with no primary preference) rated the PDM as favorable to very favorable (Gordon, 2008).

The entire article is here.

    

Prescription pain medication addiction prevalent among chronic pain patients

News Release

A new study by Geisinger Health System researchers finds a high prevalence of prescription pain medication addiction among chronic pain patients. In addition, researchers found that the American Psychiatric Association’s (APA) new definition of addiction, which was expected to reduce the number of people considered addicts who take these medicines, actually resulted in the same percentage of people meeting the criteria of addiction.

Published in the Journal of Addictive Diseases, the study found that 35 percent of patients undergoing long-term pain therapy with opioids like morphine, OxyContin, Percocet and Vicodin, meet the criteria for addiction.

“Most patients will not know if they carry the genetic risk factors for addiction,” said study lead Joseph Boscarino, senior investigator II, Geisinger Health System. “Improper or illegal use of prescription pain medication can become a lifelong problem with serious repercussions for users and their families.”
Boscarino added that “genetic predisposition to addiction further exacerbates the risks associated with misuse of prescription pain medication.”

Using electronic health records, a random sample of outpatients undergoing long-term opioid therapy for non-cancer pain was identified and 705 participants completed telephone interviews from August 2007 through November 2008.

When comparing the APA’s newly revised criteria for addiction with the old criteria, researchers were surprised to find the prevalence of and risk factors for addiction to be virtually the same. It was determined that different symptoms now qualify the same patients for inclusion who would have been excluded under the previous classification system.

The study states that pain medication addiction often happens in people under 65, with a history of opioid abuse, withdrawal symptoms and substance abuse treatment. Risk factors for severe pain medication addiction also include a history of anti-social personality disorder.

“Ultimately, we hope our research will aid the development of newer classes of medications that don’t negatively impact the brain and therefore avoid addiction entirely,” Boscarino said.

Researchers from New York University also contributed to the study.