Saturday, February 20, 2010

DSM-V: Will shoddy manual implode years before launch date?

The DSM-V debacle continues to expand like a mushroom cloud following a nuclear explosion. Media pundits right and left are commenting critically on the draft manual, published online after years of cloak-and-dagger secrecy.

As most of you know by now, the American Psychiatric Association has granted the public a very brief window in which to comment online on the draft proposals. I haven't seen an explanation of how public input will be tallied or used. Will a popularity contest influence psychiatric diagnosis? We've seen how well citizen input works here in California, where the initiative process has brought government to a standstill. Can you imagine neurologists setting up a website to get lay input on a new diagnostic scheme for brain tumors? This debacle only underscores the point that the DSM is more politics than science.

Among the best commentaries I've seen this week are Sally Satel's op-ed in the Wall Street Journal and Allen Frances' piece in Psychiatric Times. Science magazine also has an interesting analysis of the proposed behavioral disorders, which would medicalize harmful habits like gambling, overeating, and down the line perhaps "Internet Addiction." All three articles touched on the negative forensic consequences of the radical proposed changes.

"Prescriptions for Psychiatric Trouble"

Psychiatrist Sally Satel, a resident scholar at the American Enterprise Institute, lecturer at Yale University School of Medicine, and a brilliant thinker, critiqued psychiatry's endless drive to expand mental disorder, placing ever-larger "swaths of the population under the umbrella of pathology." As Satel points out, the DSM-V continues the troubling tradition, launched 30 years ago with publication of the manual's third edition, of elevating reliability over validity:

[J]ust because two examiners concur that a person qualifies for a particular diagnosis does not mean that he has an authentic mental illness. How do we know, for example, that a person diagnosed with major depressive disorder (the formal designation for pathological depression) is not actually suffering from a bout of natural if intense sadness brought on by a shattering loss, a grave disappointment or a scathing betrayal?

The manual will not help us here. In fact, a number of changes proposed for the DSM V (e.g., new diagnoses for binge eating, hoarding and hypersexuality) are likely to inadvertently place large swaths of normal human variation under the umbrella of pathology.
Both she and Allen Frances, former chair of both the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, believe that Psychosis Risk Syndrome may be the scariest example of overinclusion. Hundreds of thousands of young people, especially the poor and minorities, could be given this highly stigmatizing label and medicated with extremely dangerous drugs, even though these medications are not very effective and the broad majority of these youngsters would not go on to develop psychoses if left alone.

In his critique in Psychiatric Times, aptly titled "Opening Pandora's Box," Frances notes that the DSM-V "would create tens of millions of newly misidentified false positive 'patients.' " Not only could almost anyone qualify for at least one of the new diagnoses (which include such nebulous constructs as Mixed Anxiety Depressive Disorder, Minor Neurocognitive Disorder, Temper Dysfunctional Disorder with Dysphoria, and -- in a big nod to America's 12-Step religion -- Addiction Disorder), but thresholds are being lowered for many existing disorders as well.

Forensic applications: Disastrous unintended consequences

One of the DSM-V developers' most troubling weaknesses is their profound "insensitivity to possible misuse in forensic settings," Frances notes. As an example, he cites Pedohebephilia, "one of the most poorly written and unworkable" proposals in the draft:
Expanding the definition of pedophilia to include pubescent teenagers would medicalize criminal behavior and further the previously described misuse of psychiatry by the legal system. Certainly, sex with under-age victims should be discouraged as an important matter of public policy, but this should be accomplished by legal statute and appropriate sentencing, not by mental disorder fiat.
Two other potential "forensic disaster[s]" are Hypersexuality Disorder and Paraphilic Coercive Disorder, both of which will be used to expand the pool of sex offenders eligible for indefinite civil commitment on the basis of purported mental disorder.

In Frances' opinion, based on having worked on the three previous editions of the DSM and knowing many of the drafters of the current version, critics are missing the mark by focusing on alleged financial and/or professional conflicts of interest. Rather, the DSM-V work group members are sincere and well meaning, but have a natural, "and seemingly irresistible," tendency to expand the boundaries of diagnoses in order to identify and treat all potential sufferers. This "diagnostic imperialism" produces a fatal blind spot:
Unfortunately, Work Group members … [miss] the fact that every effort to reduce the rate of false negatives must inevitably raise the rate of false positives (often dramatically and with dire consequences). It is inherently difficult for experts, with their highly selected research and clinical experiences, to appreciate fully just how poorly their research findings may generalize to everyday practice -- especially as it is conducted by harried primary care clinicians in an environment heavily influenced by drug company marketing…. [T]he DSM5 suggestions display the peculiarly dangerous combination of nonspecific and inaccurate diagnosis leading to unproven and potentially quite harmful treatments.
Frances strongly argues that the time to weed out implausible and even "incoherent" proposals is now, not after the proposed field testing:
I feel it is my responsibility to raise clear alarms now because the past performance of the DSM5 leadership does not inspire confidence in its future ability to avoid serious mistakes.... Field trials are arduous and expensive and make sense only for testing the precise wording of criteria sets that have a real chance of making it into the manual -- not for the many poorly written and far out suggestions that have just been posted. It seems prudent to identify and root out problems now lest they sneak through in what will likely be an eventual mad rush to complete DSM5....

Because of the secretive and closed nature of the DSM5 process, the expectable enthusiasms of the experts who comprise the Work Groups have not been balanced, as they must always be, with real world practical clinical wisdom and a careful risk/benefit analysis of the possible unintended consequences of every suggestion.

It would be reckless now to rely on the complacent assumption that all these problems will eventually come out in the wash. By its previous actions and inactions, the DSM5 leadership has sacrificed any "benefit of the doubt" faith that their process will be self-correcting in a way that guarantees the eventual elimination all of the harmful options.
Note: If you want to read Sally Satel's op-ed, do it now; after seven days, Wall Street Journal articles are only available by subscription. I highly recommend that forensic experts and attorneys carefully review Frances' article, and note his recommendation for greater forensic oversight. At minimum, if new diagnoses without established validity are included in the manual, the DSM should add a caveat that they are never to be used as grounds for civil commitment.

Special hat tip to the ever-helpful JANE

4 comments:

  1. I had not seen Dr. Frances comments before but they gave me a grim laugh, especially his comments about pedophilia. It’s remarkable that after all this time he has finally conceded that the DSM IV lead to a major mess and now is hurriedly trying to stuff the cat back into the bag. Too little, too late.

    Dr Frances writes, “Expanding the definition of pedophilia to include pubescent teenagers would medicalize criminal behavior and further the previously described misuse of psychiatry by the legal system. Certainly, sex with under-age victims should be discouraged as an important matter of public policy, but this should be accomplished by legal statute and appropriate sentencing, not by mental disorder fiat.”

    The problem with his statement is that it entirely ignores the last 20 years. Sex with under-age victims (however defined) has been criminalized because psychologists have insisted for the last 20 years that it’s medically harmful. The DSV V isn’t proposing anything new in this area. It’s simply codifying what psychologist have been telling state legislatures for years; an activity that was encouraged in no small part because of the changes overseen by Dr. Frances in the DSM-IV.

    The more fundamental problem is illustrated by Dr. Satel’s comment about “large swaths of normal human variation.” If pedophilia is not inconsistent with a large swath of normal human variation then it is unclear to me how psychology can provide *any* basis for the claim that “sex with under age victims should be discouraged as an important matter of public policy.” In fact, psychology should be arguing that public policy is ill served by such criminalization. On the other hand, if pedophilia is inconsistent with normal human variation then where is the difficulty with it’s criminalization being accomplished by “mental disorder fiat”. That is an entirely unpersuasive quibble about methodology, especially in light of the de facto reality that hundreds of psychologists over the last 20 years have testified that pedophilia=the devil.

    The basic point it this. It’s entirely unconvincing for psychiatry/psychology as a profession to now go around claiming that it is being “misused by the legal system” when it has, at a bare minimum, submissively complied with that misuse and in reality has frequently encouraged the law in the behavior it now condemns. Psychology has paltered with its reputation as a science in order to achieve public influence. What is going on with the DSM V is the inevitable result of that exchange.

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  2. Also see http://www.sciencedaily.com/releases/2010/02/100220204806.htm -- "How Far Should Neuroscience Evidence Go in Court Trials?"

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  3. Good post. My feeling is that DSM-V is, in an important way, already dead - precisely because it's being criticized and discussed by so many people both inside and outside of psychiatry, before it's even arrived.

    With DSM-III and DSM-IV, the public, and professionals not involved in drawing it up, were basically presented with a big book of mental disorders and told "This is the truth". Which lent these earlier versions a lot of authority - that's why everyone called them the "Bible" of psychiatry. Sure there were critics, but they were the underdogs.

    Whereas now everyone can see that DSM-V is not absolute truth, it's the product of a long process with a lot of politics and tricky issues etc. along the way. So I think, when DSM-V does arrive, people just won't care as much as they used to.

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  4. @ Anonymous:

    I doubt you will read this, since it has been a while that you posted, but I am leaving my comments for others to read as well so they can consider the points made . . .

    >>If pedophilia is not inconsistent with a large swath of normal human variation then it is unclear to me how psychology can provide *any* basis for the claim that “sex with under age victims should be discouraged as an important matter of public policy.” In fact, psychology should be arguing that public policy is ill served by such criminalization. On the other hand, if pedophilia is inconsistent with normal human variation then where is the difficulty with it’s criminalization being accomplished by “mental disorder fiat”. That is an entirely unpersuasive quibble about methodology, especially in light of the de facto reality that hundreds of psychologists over the last 20 years have testified that pedophilia=the devil.<<

    First off, be careful how you use the term 'pedophilia". Despite the fact that so many people in mainstream American society tend to misuse it doesn't give you or anyone a green light to do the same, especially on a professionally- and intellectually-oriented forum such as this. When you do, I cannot help but dispense with your comments as possessing anything serious. Please know about that which you are discussing.

    For clarity's sake: Pedophilia is the ongoing attraction by an adult (as socially determined) for prepubescent children. If psychologists have been saying all this time that pedophilia is harmful, then that's likely in reference to sex between said adults and PREPUBESCENT children (i.e. those who have not yet entered puberty). That behavior, I would agree, is always harmful, as said children are not yet physically or psychologically ready for copulation. Adolescents, however, are a different story, and my research has found that adult-teen sexual intercourse (which is NOT pedophilic in nature and also common) is not necessarily detrimental to the youth, especial since, in many cases, the youth is the one who engages with the adult. This sort of thing happens every single day and has since time began. Adults who have had ongoing sexual encounters with adults when they were teenagers have looked back fondly on their experience and with no ill effects. That's not saying that harm doesn't occur with teenagers, only that this isn't always the case. The lower AoC in various other country's (where adult-teen sex is legal as long as [1] sex isn't forced, and [2] the youth's age falls within the AoC) testifies to this.

    All that said, I am not saying that I condone such behavior or that I encourage anyone to break the law; I am only clarifying that pedophilia has a specific reference for a reason--that prepubescent youth are incapable of engaging in sexual intercourse--and that this is probably why psychologists have called it harmful in the past. The AoC is arbitrary and not indicative of natural or evolutionary conditions, only the social attitudes and legal stances in a particular region.

    a.k.a. R1

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