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Why the Newest Psychiatric Diagnostic Bible Will Be a Boon for Big Pharma

By 5-HT2A, Feb 10, 2013 | Updated: Feb 10, 2013 | | |
  1. 5-HT2A
    The DSM-5 will likely lead patients down a road of over-diagnosis and over-medication.

    February 8, 2013

    After the American Psychiatric Association (APA) approved the latest version of its diagnostic bible, the DSM-5, psychiatrist Allen Frances, the former chair of the DSM-4 taskforce and currently professor emeritus at Duke, announced, “This is the saddest moment in my 45-year career of practicing, studying and teaching psychiatry” (“A Tense Compromise on Defining Disorders”).

    The DSM-5 (the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders) will be released by the APA in spring 2013. However, Frances states, “My best advice to clinicians, to the press, and to the general public—be skeptical and don't follow DSM-5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication.”

    For mental health professionals, this advice from the former chair of the DSM-4 taskforce is shocking—almost as if Colin Powell were to advise U.S. defense and state department employees not to blindly follow all administration orders. Particularly upsetting for Frances is the DSM-5’s pathologizing of normal human grief. On Jan. 7, 2013 in “Last Plea To DSM-5: Save Grief From the Drug Companies,” Frances wrote, “Making grief a mental disorder will be a bonanza for drug companies, but a disaster for grievers. The decision is also self-destructive for DSM-5 and further undermines the credibility of the APA. Psychiatry should not be mislabeling the normal.”

    In the DSM-4, which Frances helped create, there had been a so-called “bereavement exclusion,” which stated that grieving the loss of a loved one, even when accompanied by symptoms of depression, should not be considered the psychiatric disorder of depression. Prior to the DSM-5, the APA had acknowledged that to have symptoms of depression while grieving the loss of a loved one is normal and not a disease. Come this spring, normal human grief accompanied by depression symptoms will be a mental disorder. Psychiatry’s official diagnostic battle is over. Mental illness gatekeepers such as Frances who are concerned about further undermining the credibility of the APA have lost, and mental illness expansionists —psychiatry’s “neocons”— have won.

    Other New DSM-5 Mental Illnesses

    The pathologizing of normal human grief is not the only DSM-5 embarrassment for Frances. (See his December 2012 blog: “DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes.”) Get ready to hear about a new mental illness diagnosis for kids: “disruptive mood dysregulation disorder” (DMDD). Frances concludes DMDD “will turn temper tantrums into a mental disorder.”

    The APA, somewhat embarrassed by the huge increase of children diagnosed with “pediatric bipolar disorder” in the last two decades, wanted to give practitioners a less severe diagnostic option for moody kids. However, Frances’ fear is that DMDD “will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children....DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.”

    The DSM-5 also brings us “minor neurocognitive disorder”—the everyday forgetting characteristic of old age. For Frances, this will result in huge numbers of misdiagnosed people, a huge false positive population of people who are not at special risk for dementia. And he adds, “Since there is no effective treatment for this ‘condition’ (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.”

    “Binge eating disorder” has also now made it to the major leagues as an official DSM-5 mental illness (moving up from a non-official mental illness status in Appendix B in DSM-4). What constitutes binge eating disorder? Frances reports, “Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called binge eating disorder.”

    Frances’ “10 Worst Changes” in the DSM-5 also includes the following: “First-time substance abusers will be lumped in definitionally with hardcore addicts despite their very different treatment needs and prognosis and the stigma this will cause.” DSM-5 also introduces us to the concept of “behavioral addictions,” which Frances points out “eventually can spread to make a mental disorder of everything we like to do a lot.” Additionally, Frances reports that “DSM 5 will likely trigger a fad of adult attention-deficit disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.” And Frances adds that “DSM 5 obscures the already fuzzy boundary between generalized anxiety disorder and the worries of everyday life.”

    Brief History of the DSM

    The first DSM was published in 1952 and lists 106 disorders (initially called “reactions”). DSM-2 was published in 1968, and the number of disorders increased to 182.

    Both the first DSM and DSM-2 included homosexuality as a mental illness. In the 1970s, coinciding with the heightened significance of the DSM was the rise of gay activism. Thus, the elimination of homosexuality as a mental illness became the most visible psychiatric-political issue. Gay activists staged protests at American Psychiatric Association conventions. The APA was fiercely divided on this issue, but homosexuality as psychopathology was ultimately abolished and then excluded from the DSM-3, published in 1980.

    Though homosexuality was dropped from DSM-3, diagnostic categories were expanded in the DSM-3 to 265, with several child disorders added that would soon become popular, including “oppositional defiant disorder” (ODD).

    DSM-4, published in 1994, has 297 disorders and over 400 specific mental illness diagnoses. L.J. Davis, in the February 1997 issue of Harper’s, wrote a book review of the DSM-4 titled “The Encyclopedia of Insanity: A Psychiatric Handbook Lists a Madness for Everyone,” wrote that the DSM-4 “is some 886 pages long and weighs (in paperback) slightly less than three pounds; if worn over the heart in battle, it would probably stop a .50-caliber machine-gun bullet at 1,700 yards.”

    Mental illness expansionism in the DSM-5 is no laughing matter for Allen Frances who reminds us: “New diagnoses in psychiatry are more dangerous than new drugs because they influence whether or not millions of people are placed on drugs—often by primary care doctors after brief visits.” Though the APA claims that DSM-5 will not significantly add to the DSM-4 total of mental illnesses, by one DSM-5 declaration aloneeliminating the bereavement exclusion to depressionthey will have created millions more mentally ill people.

    DSM: Dogma or Science?

    How exactly do certain human behaviors become a mental illness? It comes down to the opinion of a board of trustees of the American Psychiatric Association. Davis writes in Harper’s, “First, and primarily, the DSM-4 is a book of dogma, though as theology it is pretty pedestrian stuff.”

    Is the DSM dogma or, as establishment psychiatry would claim, science?

    Two important aspects of a scientific instrument are validityand reliability. DSM scientific validity would mean that behaviors labeled as disorders and illnesses are in fact disorders and illnesses. And DSM reliability would mean that clinicians trained in DSM criteria agree on a diagnosis.

    One historical example, a century before the first DSM, of a clearly invalid mental illness is drapetomania. Louisiana physician Samuel A. Cartwright was certain he had discovered a new mental disease. After studying runaway slaves who had been caught and returned to their owners, Cartwright concluded in an 1851 report to the New Orleans Medical and Surgical Journal that these slaves suffered from drapetomania, a disease causing them to flee.

    While virtually all psychiatrists today rightfully mock the idea that fleeing slavery could be considered a valid mental illness, it was not until the 1970s that cultural upheaval and political protests persuaded the APA of the invalidity of homosexuality as a mental illness.

    And while homosexuality was dropped from the 1980 DSM-3, oppositional defiant disorder (ODD) was added, and ODD is now a popular child and adolescent diagnosis. The symptoms of ODD include “often actively defies or refuses to comply with adult requests or rules” and “often argues with adults.” Is it any more valid to label teenage rebellion and anti-authoritarianism as a mental illness than it is to label runaway slaves as mentally ill?

    Even if you believe that oppositional defiant disorder and all the other DSM disorders are in fact valid mental illnesses, for them to be considered scientific, they have to be able to be reliably diagnosed.

    In a landmark 1973 study reported in Science, David Rosenhan sought to discover if psychiatry could distinguish between “normals” and those so “psychotic” they needed to be hospitalized. Eight pseudopatients were sent to 12 hospitals, all pretending to have this complaint: hearing empty and hollow voices with no clear content. All pseudopatients were able to fool staff and get hospitalized. More troubling, immediately after admission, the pseudopatients stated the voices had disappeared and they behaved as they normally would but none were immediately released. The length of their hospitalizations ranged from seven to 52 days, with an average of 19 days, each finally discharged diagnosed with “schizophrenia in remission.”

    Psychiatry was embarrassed by Rosenhan and other critics and knew if the DSM wasn't fixed, they would continue to be mocked as a science. The 1980 DSM-3 was dramatically altered to have concrete behavioral checklists and formal decision-making rules, which psychiatry hoped would solve its diagnostic reliability problem. But did it?

    Herb Kutchins and Stuart A. Kirk are coauthors of two books investigating this claim of “new and improved” reliability of the DSM-3 and DSM-4: The Selling of DSM: Rhetoric of Science in Psychiatry (1992), and Making Us Crazy, DSM: The Psychiatric Bible and the Creation of Mental Disorders(1997).

    Kutchins and Kirk detail a major 1992 study done to examine the reliability of the supposedly new and improved DSM-3. This reliability study was conducted at six sites in the United States and one in Germany. Experienced mental health professionals were given extensive training in how to make accurate DSM diagnoses. Following this training, pairs of clinicians interviewed nearly 600 prospective patients. Because of the extensive training, Kutchins and Kirk note, “We would expect that diagnostic agreement would be considerably lower in normal clinical settings.” The results showed that the reliability of the DSM-3—even with this special training—was not superior to the earlier unreliable editions of DSM, and in some cases it was worse. Kutchins and Kirk summarize:

    What this study demonstrated was that even when experienced clinicians with special training and supervision are asked to use DSM and make a diagnosis, they frequently disagree, even though the standards for defining agreement are very generous....[For example,] if one of the two therapists....made a diagnosis of Schizoid Personality Disorder and the other therapist selected Avoidant Personality Disorder, the therapists were judged to be in complete agreement of the diagnosis because they both found a personality disorder—even though they disagreed completely on which one!...Mental health clinicians independently interviewing the same person in the community are as likely to agree as disagree that the person has a mental disorder and are as likely to agree as disagree on which of the...DSM disorders is present.

    Kutchins and Kirk report there is not a single major study showing high reliability in any version of the DSM, including the DSM-4.

    Is there any good news about the DSM-5? The APA just announced that its price for the DSM-5 will be $199 a copy, and this is good news for Allen Frances who reacted: “People are not likely to rush out to buy a ridiculously expensive DSM-5 that has already been discredited as unsafe and scientifically unsound...The good news is that its lowered sales and lost credibility will limit the damage that can be done by DSM-5.”

    By: Bruce E. Levine

    Source: Alternet


  1. Moving Pictures
    That's scary. And dangerous. It's normal to be depressed if you lose a loved one. No amount of anti-depressant drugs are going to make you feel better because nothing is wrong with your brain chemistry. Now if you weren't depressed when you lost someone, then you might have something wrong with you. I want to read the criteria for diagnosing someone with this. If 6 months later you're still misreable and can't get out of bed, yeah, you probably need some medication. But like I said, it's normal to feel some degree of depression, even severe depression, after losing a loved one.
  2. talltom
    As DSM-5 Launches, the Drama Ends and the Effects on Addiction Begin

    The the newly revised, hotly contested book of psychiatric diagnoses is finally here. The newest edition of psychiatry's "bible" of diagnosis, the DSM-5, made its long-awaited appearance on May 18 at the opening of the American Psychiatric Association’s (APA) national conference in San Francisco. This revision of the DSM-IV took the APA more than a decade to produce, and unprecedented criticism dogged it most of the way.

    Because of the unique role the DSM-5 plays in the diagnosis of addiction—and, as a result, its influence on the allocation of billions of dollars for research, prevention and treatment—The Fix has devoted extensive coverage in recent months to the controversies. Now, with the book launched and the dust settling, we turn our attention to two questions about short- and long-term consequences, and what people with substance use problems stand to gain or lose:

    • Will treatment for addiction become more accessible for more people?

    • Will research into addiction produce more effective diagnostics and drugs?

    1. The Promises and Perils for Treatment

    The DSM-5 arrives in the midst of an historic overhaul of the nation's healthcare system under Obamacare (aka the Patient Protection and Affordable Care Act, or ACA ). Together, the legislation and the diagnostics revision are likely to dramatically increase the number of Americans eligible for addiction treatment. But the noble goal of securing more care for substance users could have an unintended consequence, some experts warn: stretching an already-overwhelmed patchwork of services past their limits.

    Once Obamacare kicks in, as many as 5 million people with substance use disorder will be newly eligible for insurance, according to an Associated Press analysis. The quandary: In most states, patients already fill treatment centers to the brim. The worst-hit states have only one rehab or hospital bed available for every 100 people in need of inpatient care. The new arrivals could double the existing wait-lists.

    The DSM-5 revisions were based on the same healthcare research that shaped Obamacare, and will work in tandem with the legislation to encourage early intervention in substance use disorders, Charles O'Brien, MD, PhD, head of the University of Pennsylvania's Center for Studies in Addiction and chair of the DSM-5's Substance-Related Disorders Work Group, told The Fix. By defining substance use disorder across a spectrum from “mild” to “moderate” to “severe,” the revision could add as many as 20 million more substance use diagnoses, Keith Humphreys, PhD, a Stanford psychology professor who served as a senior advisor on drug policy under Obama, told The New York Times.

    That jump in diagnoses, paired with the ACA's expansion of coverage, will present a formidable challenge to already-shrinking addiction services. And since the majority of new diagnoses will likely be people in the initial stage of disease, critics fear that the most severe cases most in need of treatment will lose out. “Our scarce [addiction] resources are already distributed in an irrational manner,” Allen Frances, MD, who headed the DSM-IV revision, wrote in Bloomberg News. “We badly shortchange those with clear disorders while overtreating essentially normal people.”

    That alarm misrepresents the large-scale, long-term changes likely to result from the one-two punch of expanded insurance and diagnosis, Humphreys told The Fix. "I think that's a misplaced concern and an old way of looking at things," he said, because it fails to consider how Obamacare will transform the provision of addiction treatment. To be blunt, insured patients can pay medical bills, so the new healthcare law will make addiction profitable. That will move the bulk of substance use care from the realm of government funding to that of private enterprise.

    Insured patients can pay medical bills, so Obamacare will make addiction profitable, encouraging private enterprise.

    Hospitals and other private health centers will realize that the millions of newly insured addicts represent a source of customers, which could prompt their rapid expansion, Humphreys said. In another benefit, the provisions will likely shift services away from residential and stand-alone programs toward outpatient and integrated care systems.

    But in the short term, Humphreys admits, there will be lag time before these “market adjustments” take effect. “While it's being figured out, some people will have a tougher time getting treatment,” he said.

    The prospect of more accessible treatment for more people is based on two major changes in the ACA:

    Medicaid: Obamacare’s main strategy to cover most of the 30 million uninsured Americans is by an enormous expansion of this government program for the poor. (Health exchanges will allow uninsured people who do not qualify for Medicaid to shop for competing private insurers.) In the past, Medicaid covered only half of mental health and substance use services. New rules have extended that to two-thirds, and come January 2014, it will reach 100%.

    Parity: Under new "parity-plus" laws, health insurers will have to cover mental health and addiction care at the same rate as physical maladies.

    But the Medicaid expansion may look better on paper than it works in reality. Why? Because the Supreme Court ruled last year that states have the right to restrict it. As a result, the effectiveness of the legislation will partly depend on whether or not states choose to implement the changes, said Susan Foster, MSW, vice president and director of policy research and analysis for the National Center on Addiction and Substance Abuse at Columbia University. Political agendas opposed to government spending appear to have shaped these choices, at least for the time being.

    In additional changes, Obamacare relies heavily on cost-effectiveness—via prevention and early intervention—to bend the curve of runaway healthcare costs. And that's where the DSM-5 links arms most closely with the new Medicaid requirements, thanks to the manual's new “spectrum” approach to defining substance use disorder. The "mild" end of the DSM-5's substance-use spectrum will help healthcare providers identify patients at risk of, or in the first stages of, addictive behavior, O'Brien said. The DSM, in other words, will serve as a guide to help clinicians follow ACA mandates.

    For example, a protocol called Screening, Brief Intervention and Referral to Treatment (SBIRT) has shown success at halting substance use disorder before it gains much momentum. Yet insurers have refused to cover SBIRT, limiting the program's actual use. Obamacare aims to change that, mandating that Medicaid and state-exchange insurance plans cover SBIRT as a prevention benefit provided by primary-care physicians and in hospital emergency rooms.

    “I think the DSM-5 and Obamacare should work well together, synergistically," Humphreys said.

    Yet this spectrum definition of addiction prompts dire predictions of critics like Frances, who say the change will increase diagnoses by, for example, turning "normal" binge drinking into "substance use disorder" requiring treatment.

    The research is mixed on whether or not that will happen. While an Australian study did, in fact, predict a shocking 62% increase in "alcohol use disorder" diagnoses under the DSM-5, two US studies estimated much smaller increases (of 11% and 5%). “I doubt that the increase in diagnoses is going to be significant,” Foster told The Fix.

    Patients identified on the "mild" end won't compete for services with full-blown addicts, anyway, Humphreys said. The two groups will get different kinds of care from different kinds of providers, with primary care physicians expected to handle most issues for mild abusers. "Early intervention is not about sending the guy who drinks two days a week to rehab,” Humphreys said.
    Instead, clinicians can tailor treatment to each patient depending on the severity of his or her problem—rather than lumping all substance users together, Foster said. People who want to get control of an early-stage disorder may be “prescribed” a choice among, or combination of, 12 Steps, behavioral therapy and anti-craving medication, for example. By contrast, those with a severe substance use disorder may require inpatient treatment at a hospital.

    "The diagnostic criteria help people understand that addiction is a disease," she said, "and that you have different levels of severity that call for different treatments."

    Whether or not the ACA and DSM-5 work as planned to increase the quantity and quality of healthcare for people with addictions remains to be seen. There are countless potential hurdles. But one thing is clear: A major transformation in addiction diagnosis and treatment is underway, replacing a system that offers enormous room for improvement.

    2. The Brain Scientists vs. the Mind Doctors

    Right before its birth, the DSM-5 suffered perhaps its biggest rebuke. The world's largest psychiatric research organization, the National Institute of Mental Health (NIMH), rejected the very “validity” of the DSM’s approach to diagnosing mental illness.

    The institute's director Thomas Insel, MD, went beyond the now-familiar complaints that the manual includes too many disorders, or the wrong ones, announcing that the traditional use of symptoms as a basis for diagnosis is hopelessly outdated—and that the NIMH would do its best to usher that system to the exits. “The NIMH will be re-orienting its research away from DSM categories…and supporting…emerging [scientific] research [such as] genetic, imaging, physiologic, and cognitive data,” Insel wrote.

    The dominance of the DSM system has hampered that research, Insel said, preventing scientists from pinpointing the real causes of psychological suffering.

    Holding the biggest purse in mental health research, the NIMH's decision will redirect the way money flows to addiction research—and, ultimately, how addicts are diagnosed and treated. The agency aims to replace symptom-based diagnoses with “biomarkers"—objective medical measures for psychiatric diagnosis that would be the mental health equivalent of blood pressure measures.

    These markers, however, are currently little more than speculative. To discover them, the NIMH has launched its RDoC, or Research Domain Criteria project. While the NIMH won't be "abandoning" the DSM immediately, the agency's research money will increasingly go to studies that buck the DSM in favor of RDoC criteria, said Bruce Cuthbert, PhD, director of the NIMH's Division of Adult Translational Research and Treatment Development.

    Though the National Institute for Drug Abuse (NIDA) and National Institute of Alcohol Abuse and Alcoholism (NIAAA) handle most addiction-specific research funding, they cooperate with the NIMH on many projects, said Wilson Compton, MD, director of NIDA's Division of Epidemiology, Services and Prevention Research. The head of NIDA, Nora Volkow, MD, has led a veritable campaign to redefine substance use disorder as a brain disease best studied by the tools of neuroscience.

    “The NIMH will re-orient its research away from the DSM and toward genetic, imaging and cognitive data,” Insel wrote.

    Coupled with Volkow’s priorities, the NIMH shift from soft to hard science will likely have a lasting effect on addiction research. "I wouldn't be surprised if these other organizations don't incorporate the new [RDoC] categories,” said Warren Bickel, MD, director of the Addiction Recovery Research Center at Virginia Tech Carilion Research Institute.

    And that will change where the money for addiction research goes. Traditionally, to get funding, mental health studies have had to show their scientific validity by declaring which DSM-defined disorder they would investigate. Unfortunately, as Insel and many other scientists have said, mounting evidence suggests that DSM diagnoses simply don't match up with what's happening in patients' brains.

    The system suffers from two main blind spots, according to critics. First, the underlying causes of mental suffering do not fit neatly into labels like "schizophrenia" or "substance abuse." Instead, these causes cut across many different DSM diagnoses. For example, malfunctions in what neurologists call the reward-circuit—the brain system that makes food, sex, alcohol, etc., pleasurable—occur in multiple disorders, including depression and addiction. Second, because the DSM lists so many criteria within each disorder, two patients can have completely different symptoms and yet receive the same diagnosis—as long as they meet the same number of criteria.

    Addiction research is currently focused intensely on the brain's pleasure pathway and the brain chemical dopamine, asking if it is the true seat of addiction disorders. But scientists admit that given the brain's intricate complexity, the more they learn, the less they know. As the long as such biological causes of addiction remain a mystery, however, identifying precise targets and developing effective drugs are stymied.

    RDoC-guided investigations won't produce results that affect diagnosis for years. That means the DSM remains the best available choice for clinicians who need to diagnose real problems in real patients, Cuthbert said.

    Others, like Randy Brown, MD, director of the Center for Addictive Disorders at the University of Wisconsin-Madison Hospitals and Clinics, worry that research realignments like RDoC—together with President Obama’s “Brain Initiative,” a public-private research partnership—will steer money away from studies that could offer here-and-now benefits. "What's happening with the patient and the community has immense value," he said, “more so, sometimes, than a lot of the neurophysiological approaches."

    Brown's concern about the NIMH's brain-centered approach echoes another recent, high-profile takedown of the DSM-5. The British Psychological Society (BPS) called last month for the abandonment of the DSM as an outdated collections of symptoms. But in their view, the problem stems from a focus on biology, including the neurological substrates that the NIMH wants to elevate. "The implicit theory [of the DSM] is one of biological reductionism," said Steven Coles, a clinical psychologist and co-author of the BPS statement. "We can do far more than we do to focus on psychological and social aspects" ranging from bereavement to unemployment."

    Insel's announcement still signals a shift, however, and the DSM won't be around forever—on the research or diagnosis sides, Bickel said. "We're moving into a bold, new future where the influence of the DSM is on the wane."

    For people battling addiction, that means a more scientific system in addiction care—someday. The future could see doctors analyzing MRI readings of your brain circuitry and tests of your genes to diagnose a substance use disorder. Only well-funded basic research will get us there, but until then, this much-maligned manual that is, after all, the repository of decades of psychiatric knowledge, will remain necessary.

    Michael Dhar
    The Fix
    May 21, 2013

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