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    The DSM-V: The New, The Revised, The Opportunities For Pharma
    By Becky Jungbauer | February 10th 2010 12:01 PM | 10 comments | Print | E-mail | Track Comments
    About Becky

    A scientist and journalist by training, I enjoy all things science, especially science-related humor. My column title is a throwback to Jane

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    If the folks behind the Diagnostic and Statistical Manual of Mental Disorders (DSM) were crafty, they would have latched on to the upcoming movie, "The Crazies," for some free publicity.1 Although that's probably not quite the image they want to convey, so maybe it was a shrewd non-move after all. Well played, American Psychiatric Association.

    For those not in the know, the DSM is the "Bible" for physicians, researchers and insurance companies. The manual "contains descriptions, symptoms and other criteria for diagnosing mental disorders," according to the APA. "These criteria for diagnosis provide a common language among clinicians ... to ensure that a diagnosis is both accurate and consistent; for example, that a diagnosis of schizophrenia is consistent from one clinician to another, and means the same thing to both of these clinicians, whether they reside in the U.S. or other international settings." 

    The DSM can also be used by researchers and by insurance companies (for coverage decisions). A common misconception is that the DSM makes treatment recommendations - it doesn't. It aids physicians in arriving at a diagnosis, which will determine a treatment plan, but makes no recommendations on what that plan should be.

    The manual has been revised occasionally, since its inception in 1952, to update "criteria for diagnoses that not only reflect new advances in the science and conceptualization of mental disorders, but also reflect the needs of our patients." The new draft out now will become the DSM-V (roman numeral 5, not the letter V).2

    So what's new in the draft?


    A few things are called out by the APA as being of particular interest - new research on post-traumatic stress disorder, concerns about the diagnosis of gender identity disorder, possible inclusion of non-substance addictions (gambling and Internet), how to better predict a patient's risk of suicide, clarification between bipolar and unipolar, and the possible inclusion of a "risk" syndrome, where clinicians could classify someone at risk of developing a psychosis (much like cholesterol or blood sugar levels are used in heart disease and diabetes).

    The idea isn't to further dissect and narrow the disease categories, but rather to "'capture more central themes' about what defines a disorder," the DSM-V task force chairman told the WSJ.

    I've taken a step-by-step look at the various changes in the draft, and have highlighted them below for your reading pleasure:

    Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence


    This will be a biggie. Among the proposed changes are a new disorder, potentially labeled temper dysregulation with dysphoria (though other diagnostic labels, including severe mood dysregulation, are being considered); and a callous/unemotional specifier for conduct disorder. The task force is treading very carefully here, as this could be a minefield. They're also thinking about moving Asperger's into the autistic spectrum.

    Delirium, Dementia, Amnestic and Other Cognitive Disorders

    They want to divide the category into three "broad syndromes: Delirium, Major Neurocognitive Disorder, and Minor Neurocognitive Disorder." This group also wants to categorize behavioral disturbances, particularly the syndromes of psychosis and depression, associated with Neurocognitive Disorders, and select specific domains as well as measures of severity of cognitive functional impairment.

    Mental Disorders Due to a General Medical Condition Not Elsewhere Classified


    The only change here is that they'd like to replace "Catatonic Disorder due to..." with a catatonia specifier.

    Substance-Related Disorders

    This is another one that I think will get a lot of attention, from the media, physicians, patients and especially pharmaceutical companies. First, they want to include both substance use disorders and non-substance addictions. They also want to re-title the category "Addiction and Related Disorders," to get away from the substance part of the definition, because they want to include gambling addiction (currently listed under Impulse-Control Disorders Not Elsewhere Classified) and other addictions like Internet here, as data accumulate. The inclusions and revisions are numerous, so I'll let you read them yourself instead of listing them here.

    Schizophrenia and Other Psychotic Disorders

    The most interesting change here is the proposal for a psychosis risk syndrome, and whether it should be included in the main manual or in an Appendix for Further Research. The rationale for this is that "young people at risk for later manifestation of a psychotic disorder can be identified. It has been established in follow-back studies that early signs and symptoms of schizophrenia, for example, are present years before diagnosis is established." The potential benefit to including this syndrome, the task force says, is that "psychotic illness is most effectively treated early in the course, raising the potential that early intervention may have long lasting benefit that is not achievable with later therapeutic intervention."

    In my personal opinion (and I'm not a psychiatrist, so I'm not speaking for the APA or anyone else), I think this could be one of the most important changes in the DSM. Clearly, as the task force says, you have to consider critical issues like sensitivity and specificity of diagnostic tests, positive and negative predictive power, evidence for effective intervention, and issues related to stigma and potential harm of excessive treatment. But think about the possibilities to benefit so many people - not just the patients, but the patients' families and those who come in contact with the patient. A great analogy is cholesterol levels for heart disease, or even blood sugar levels for diabetes - if you can work on keeping these in check, you can prevent or delay possible negative outcomes. Of course, clogged arteries aren't the same as a neurochemical imbalance, but the idea is there. And this is taking things to extremes, but what if you can predict that someone will have a severe psychotic disorder and treat that - could you possibly stave off any future repercussions like crimes?

    This would have to be rigorous and well-researched so it doesn't turn into the next big thing, like every kid who has a temper tantrum has ADHD or every person who is sad once in a while gets Prozac.

    Mood Disorders


    There are a number of revisions here, mainly about moving things around. Two issues of note - one, the task force wants to include an anxiety dimension across all mood disorder categories as well as a suicide assessment dimension. These would be akin to a co-morbid diagnosis (e.g. depression AND anxiety), but would be more integrated (e.g. depression with 3 of 4 anxiety symptoms). The other issue is that of a new diagnosis for mixed anxiety depression, in which a patient has three or four of the symptoms of major depression which are accompanied by anxious distress.

    Anxiety Disorders

    This category has all sorts of things happening - revisions, inclusions, movements, etc. Two new proposed disorders are hoarding (not sure about whether to include this in the main manual or the appendix) and skin picking (likely to be placed in the Appendix). Another proposed new disorder was one I had to click on because I had no idea what it meant: Olfactory Reference Syndrome - a "preoccupation with the belief that one emits a foul or offensive body odor, which is not perceived by others." I think the opposite is true for most high school and college-aged males; they smell and it is definitely perceived by others but they don't know it. (Or care.) The task force also wants to revise how a mental disorder is defined (see here).

    Somatoform Disorders


    These are generally comprised of psychological disorders that manifest in physical symptoms. The task force wants to rename the category Somatic Symptom Disorders to better clarify that.

    Factitious Disorders

    They want to get rid of this category and move factitious disorders into Somatic Symptoms. Factitious disorders are when a person acts as if he or she has an illness by deliberately producing, feigning, or exaggerating symptoms (you may have heard of Munchausen's).

    Dissociative Disorders

    The task force wants to move a few of these into other categories and leave the rest alone for the most part.

    Sexual and Gender Identity Disorders


    This will be a flashpoint for a lot of people. New disorders for proposed inclusion are hypersexual disorder (what you might think of colloquially as sex fiends), paraphilic coercive disorder (urges focused on coercive sex), sexual interest/arousal disorder in women and in men, and a penetration pain disorder. A point of controversy will be the Gender Identity Disorders, which the task force would like to rename Gender Incongruence. APA says the "diagnosis of Gender Identity Disorder has created concerns among members of the gay/lesian/bisexual/transgender community, questioning whether the condition is a mental disorder, a physical disorder or a normal variation of human behavior. While much of the concern has centered around treatment, which DSM does not address, the APA will still address issues of diagnosis."

    Eating Disorders

    The task force wants to rename this the Eating and Feeding Disorders category to reflect inclusion of feeding disorders. Also, they want binge eating disorder be recognized as a free-standing diagnosis apart from the Appendix.

    Sleep Disorders

    The task force wants greater inclusion of disorders not listed in the mental disorder section of the International Classification of Diseases, as a way to "educate non-expert sleep clinicians (such as psychiatrists and general medical physicians) about sleep disorders that have mental as well as medical/neurological aspects." There are some new inclusions, like Restless Legs Syndrome, that will lend credibility to RLS patients and treatments. Various apneas will also get their own diagnosis, versus being categorized under Breathing Related Sleep Disorders.

    Impulse-Control Disorders Not Elsewhere Classified

    The task force wants to move pathological gambling to Substance-Related Disorders (to be renamed Addiction and Related Disorders).

    Adjustment Disorders

    This category would be rendered moot, as they want to group it with other Trauma and Stress-Related Disorders.

    Personality and Personality Disorders

    The task force wants to overhaul this category - they want "a major reconceptualization of personality psychopathology with core impairments in personality functioning, pathological personality traits, and prominent pathological personality types." For more on this, see the specific section site.

    Other Clinical Conditions that May Be a Focus of Clinical Attention

    Finally we come to the last category. This diagnostic category includes "conditions related to psychosocial and environmental problems, such as whether a patient is having housing or economic problems or problems with his/her primary support group. In addition, this category contains a listing of movement disorders related to medication use. The work groups are still discussing whether DSM-5 will contain any revisions to these conditions and diagnoses." In fact, all subtypes in this category are recommended to not be included in the DSM-V, with the exception of "Psychological Factors Affecting ... [Medical Condition]."

    What's next?

    Anyone can comment on the draft until April 20, 2010, after which the draft is put into the real world to see how it holds up in the field. The final version will be published in 2013.


    1 Yes, that's sadly an actual movie - see the IMDb site for more. Who vetted that title?
    2 To read the draft, peruse FAQs, and learn more about the DSM-V draft, visit this site. They ask for feedback from everyone, not just physicians. You can click on the various categories as I've highlighted above and find out what's proposed to be included, dropped, revised, etc and why. It's actually quite well done, in my opinion.

    Comments

    Amateur Astronomer

    Becky,

    DSM in Europe is a large corporation engaged in petroleum exploration and processing. They make chemicals originating from oil.

    The book you described is not their operation manual.

    Volume V seems to be missing a lot of blog related disorders.

    So I suppose your readers will find some topics to add to the text.

    Here are a few suggestions.

    **** Blogging during meal time, prime time Television, or when the Life Mate wants to chat.

    **** Blogging to excess on topics that have no extreme elements.

    **** Late night bogging, not fully clothed, after the computer has turned down the thermostat, also known as blue toe blogging.

    **** Cross blogging on topics that are not related to the discussion topic.

    **** Failing to laugh at Becky’s funny blogs; one of the more serious disorders.

    **** Right brained blogging on a left brained page.

    **** Blog poetry written in symbolic logic, for liberal arts majors.

    **** One guy arguing with him self in blog space. Girls don’t usually get this order.

    **** Disorderly blogging; pending a decision about whether or not this is a mental disorder.

    My list could go on, but for now maybe the other readers would like to add disorders to the list.

    Amateur Astronomer

    Diagnostic ? -- Yes

    Disorders? -- Maybe

    Statistical? -- Seems to be out of place.

    Is an ill person to be told that by a Psychiatrists that there is no treatment because the disorder is rare?

    Here are a few more suggestions for improvements.

    **** Treatable disorders that can be found in any well insured patient.

    **** Statistics on the liability of violent response to treatment.

    **** Opportunities for self treatment of Psychiatrists, all of whom seem to need something.

    Amateur Astronomer

    Does a Psychiatrists ever diagnose a person to be perfectly sane? I am happy to report the answer is a resounding yes.

    A factory in West Virginia was making powerful chemicals out of extremely dangerous materials. Originally it was built for making weapons, but the public policy stopped that a long time ago. So the factory made brake fluid for cars instead (HEED THE WARNINGS ON THE CAN) One of the operators was an authentic mountain man and the fourth generation of his family to work in the factory.

    The top manager in the factory was not of local origin and not attuned to the culture and values. After some strange discussions the manager decided the operator was insane an should be banned from the factory. There was a union contract that governed the process, and the union required proof of insanity.

    Indignantly the manager sent the operator to Charleston for Psychological evaluation. It happened that the Psychiatrist was from the same neighborhood as the operator, and found him to be perfectly sane. Then the manager was called in for evaluation, but he left town instead of going to the Psychiatrists.

    When I arrived in the factory the manager was long gone and the operator had been promoted to chief operator. His certificate of sanity was posted on the bulletin board together with the safety warnings, and the phone number of a pizza delivery service.

    The DSM is a compilation of criteria that clinicians use to have a consensus for diagnosis. It is derived from the input and experience of psychiatrists with their patients, but is simply what a group of clinicians came to an agreement on after debate and discussion. It's purpose is to standardize language between clinicians. Unfortunately, it is also the criteria with which insurance companies decide that payment will be given. If you have a diagnosis (with the appropriate code) then you have a mental illness and can get reimbursement for treatment. As a psychiatrist that works on an inpatient psychiatric unit, I understand the utility and the necessity of the DSM. I am torn, however, with some of the new inclusions proposed. Specifically, I have difficulty with trying to identify children at risk for psychosis, as well as giving individuals a diagnosis of hypersexual disorder. For kids, I think that we risk pigeon-holing them into a diagnosis and premature treatment with antipsychotic medications without scientific proof that they will develop psychosis, or other known preventative treatments at our disposal. Medications are not preventative, only palliative. Next, for those individuals meeting the criteria for hypersexual disorder, we risk giving them a way of denying responsibility for their actions, a medical rationalization of their lack of impulse control, but (and what many clinicians want and need) a way for insurance companies to justify paying for their psychiatric or psychological treatment. The struggle in medicine these days (sad but true) is to find the balance between money and patient care, because one does not exist without the other. as for Mr. Decker....I believe that I would diagnose you with Obsessive Commenting Disorder with Excessive Spacing for Effect, Moderate
    Amateur Astronomer

    Dr. C

    I'm a fan of Becky. Her writing is flesh, lively and often humorous. It's not a disorder, at least not one my insurance company would recognize. In English language blog world there are a hundred writers with familiar names. I comment on 5 of them fairly often. Last year the number was 6 but decreased to 5. It means I put Becky in the top 10 writers.

    In Spanish blog space and 4 other languages, I often read but seldom write without computer assistance.

    Excessive spacing is not of my choice, it is something the web site does automatically when converting my text into blog font. My original looks entirely different and is a lot easier to read for older people. The web master has tried several remedies. Sometimes the spacing happens and sometimes it doesn't. You diagnosed me with a computer glitch and suggested in other context that my health insurance could be billed for it. (pause for laugh here)

    Before answering your (bit of wit) comment, I asked a close friend of long time relationship for advice. She said you are much to young to understand men, although you have a positive direction in your career. Continuing beyond the scope of my question, she said that I am a compulsive reader, not a compulsive writer. I read labels on cans, foot notes in books, and gas gages on dash boards of automobiles. If I lived in New York City there would be no time available for such things.

    Now I apologize for reading your reference material before answering your comment. It's a life long quest for knowledge and understanding, not a personality disorder. In your own words:

    "I feel compelled to comment on Valentine's Day, but I find myself having great difficulty writing about it".

    It seems that you have dealt with your anxieties by externalizing then to other people. That was covered somewhere in my 12 semesters of college psychology. Those were rather easy classes that technical people took to dilute the difficult class schedules of science and math majors.

    From your web site I guess you are a specialist in sex therapy for nearly normal people who have good insurance policies covered by DSM-V. You give speeches in public for which you get paid. Also you do some clinical services that would displease Sigmund Freud. In the case of Freud, I prefer the description Peter F Ducker (an economist) gave of him. Freud lied to himself and externalized his own disorders into all of his patients. He wasn't ostracized because he was Jewish or outspoken about sex. He was shunned because he refused to do charity work that was expected of the medical profession in Vienna. From your web site I got the impression that you are better qualified on the physical side of life than on the emotional side. Maybe that was just a marketing posture for your service.

    In a long professional career I had only one publication that could be shown in public. It was a government report describing ways to prevent disasters of mass destruction from extremely dangerous materials, like those covered by the Montréal Protocol and the Geneva Accords. When I give a speech for pay, it is behind closed doors, and never published anywhere. I spent a lifetime accumulating knowledge and experience, keeping it to my self. Now a little bit is being given back in support of the small group of writers I admire.

    I'm a bit sensitive to medical abuse of well insured people. I had unnecessary surgery early in life because my father had an old style insurance policy that paid for everything. The job was badly done. The surgeon severed a major blood vessel that wasn't supposed to be touched, and I almost died on the operating table. The repair job was botched and had to be redone later. That was when I learned that the surgery was not necessary, and could have been done with a safer less expensive procedure on out patient basis. Now I am still well insured, but get good health care at reasonable cost, by asking friends for their wise advice, and managing my own health care decisions.

    In silence I watched for decades as the quality of life was systematically degraded for the majority of working people. The most prominent causes were notorious frauds committed in New York City by scoundrels who were never prosecuted. In those years I didn't have time for blogging. I was busy protecting places like Manhattan from projects of mass destruction. Later a classmate from high school days retired from a long successful advertising career in Manhattan and moved to Central America with her parting message about NYC so bad that I never repeat it. My own experiences in the big city were not so bad as long as I kept the expense account up to date, watched where I stepped, avoided some strange people, and dodged traffic.

    I believe you are suffering from a disorder resulting from long time exposure to New York City life. In that case reading Becky's column is a step toward treatment and recovery.

    Hank
    "I believe you are suffering from a disorder resulting from long time exposure to New York City life. In that case reading Becky's column is a step toward treatment and recovery." Nice enough place to visit, though.
    Becky Jungbauer
    "I'm a fan of Becky. Her writing is flesh, lively and often humorous."
    I'm going to put that on my resume.
    Amateur Astronomer

    I did remember to say long and successful career on Madison avenue, but forgot to say retirement villa in Costa Rica mountains.

    Years ago in NYC with my best friend at battery park looking at the Trade Center Towers and further up town, she asked me if I had ever been up in the Trade Towers. I replied that I thought they were unsafe and should be torn down. The Port Authority did a study and decided it would be too costly.

    A few years later the first attack occurred, and eventually the second attack that brought down the house.

    I always wondered if a few people could have tried a bit harder to prevent the disaster.

    Retirement in Costa Rica doesn't sound so bad.

    Visit to NYC is OK.

    rychardemanne
    Far too many "potential risks of unknown probability at an unknown future date" types of pseudo-diseases. Smells like the insurance companies have been drip-feeding the board.

    Corporate Risk Averse Personality (CRAP) disorder should be included. As corporations have "personhood" status most would be certified as sociopathic and should be wound down for the sake of public health.

    and thanks for the lengthy review!
    "Somatoform Disorders

    "These are generally comprised of psychological disorders that manifest in physical symptoms. The task force wants to rename the category Somatic Symptom Disorders to better clarify that."

    More insidious.

    While the media has focussed on the implications for introducing new additions into the DSM and broadening the definitions of existing diagnostic criteria, the DSM-5 "Somatic Symptom Disorders" Work Group (Chair, Joel E Dimsdale) has been quietly redefining DSM’s "Somatoform Disorders" categories with proposals, that if approved, would legitimise the potential application of an additional billable diagnosis of "Somatic Symptom Disorder" to all medical diseases and disorders.

    Radical proposals for renaming the "Somatoform Disorders" category "Somatic Symptom Disorders" and combining a number of existing categories under a new rubric, "Complex Somatic Symptom Disorder (CSSD)", and a more recently proposed "Simple Somatic Symptom Disorder (SSSD)", have the potential for bringing thousands more patients under a mental health banner and expanding markets for psychiatric services, antidepressants, antipsychotics and behavioural therapies such as Cognitive Behavioural Therapy (CBT) for the "...modification of dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors..." for all patients with somatic symptoms, irrespective of cause.

    The proposals of the "Somatic Symptom Disorders" Work Group revision have the potential for a "bolt-on" diagnosis of a "Somatic Symptom Disorder" being applied to all medical diseases and disorders, whether "established general medical conditions or disorders" and "well-recognized organic disease" for example. diabetes, heart conditions, cancer, or conditions presenting with "somatic symptoms of unclear etiology".

    By doing away with the "controversial concept of medically unexplained" and eradicating “terminology [that] enforces a dualism between psychiatric and medical conditions” the "Somatic Symptom Disorders" Work Group revision say their proposals will diminish "the dichotomy, inherent in the Somatoform section of DSM-IV between disorders based on medically unexplained symptoms and patients with organic disease".

    Under the guise of "eliminating stigma", and "divisiveness" between patients and their clinicians, the APA appears hell bent on colonising the entire medical field by licensing the application of a mental health diagnosis to all medical diseases and disorders.

    Online posting of draft disorders and criteria proposed by the DSM-5 Work Groups for new and existing mental disorders had been scheduled for May, this year. But according to a revised Timeline on the American Psychiatric Association's (APA) DSM-5 Development site, this second public review exercise is now shifted three months, to August-September 2011:

    "August-September 2011: Online Posting of Revised Criteria. Following the internal review, revised draft diagnostic criteria will be posted online for approximately one month to allow the public to provide feedback. This site will be closed for feedback by midnight on September 30, 2011."