DSM: What and When

1. DSM: What and When 11 September 2011 Roger Peele, MD, DLFAPA

2. Outline - 1 • Importance [Slide number – 4] • Fundamentals – 28 • History of DSMs – 49 • DSM-5, values – 61 • DSM-5, organization – 65 • DSM-5, Intellectual Disabilities – 67 • DSM-5, Mood disorders - 75

3. Outline - 2 8. Anxiety Disorders – 95 Hoarding Disorder – 96 9. PTSD – 105 10. Somatic Symptom Disorders – 109 11. Eating Disorders – 111 12. Sexual Disorders – 112 13. Gender Dysphoria – 118 14. Substance Use Disorders – 122 15. Multiaxial - 134

4. Importance • 1. Access to care and treatment. DSMs “is the cornerstone in the edifice of mental health care” [Sadler, 2006]. Recognized by insurance and public agencies.

5. Importance - 2 • 2. Access to entitlements.  Defines the responsibilities of public agencies accountable for the psychiatrically ill. Reimbursements are administered on the basis of the DSM [in an overlap with ICDs]. Even the location within DSM can have an impact on access, e.g., the Axis II location, some claim, decreases access.

6. Importance – 3a • 3. Approved treatments.FDA, for example, had had a tradition of asking that medication approval requests be focused on DSM entities. Some see this as having a negative consequence, causing a stall in development of medications.

7. Importance – 3b • DSM disorders, which are syndromes, some believe have not provided specific treatment targets. In 2006, the Washington Psychiatric Society had a motion approved by the APA saying that FDA should consider signs/symptoms for approval, not just dx categories.

8. Importance – 4a Research: Steve Hyman, Past-Director of NIMH: •           “Despite these successes [of the DSMs], there are clear problems and unresolved controversies related to DSM-IV-TR, the most recent version of DSM. If a relative strength of DSM is its focus on reliability, a fundamental weakness lies in the problems related to validity. Not only persisting but looming larger is the question of whether DSM-IV-TR truly carves nature at the joints – that is, whether the entities described in the manual are truly ‘natural kinds’ and not arbitrary chimeras.”

9. Importance 4b •   “In reifying DSM-IV-TR diagnoses, one increases the risk that science will get stuck, and the very studies that are needed to better define phenotypes are held back.”

10. Importance - 4 c • “Except for IQ tests to diagnose mental retardation and polysomnography to diagnose sleep disorders [polysomnography was inexplicitly excluded from DSM-IV-TR criteria sets], diagnostic tests for mental disorders do not yet exists.”

11. Importance 4 - d • “The most important goal is to help the APA get out ofthe DSM-III-R-R-R rut without blowing up clinical practice.  Whatever ittakes.” • Steve Hyman

12. Importance - 5 • 5. Education.  The teaching of psychopathology in the United States and many other countries follows the DSM.

13. Importance - 6 • 6. Legal and criminal decisions. Despite cautionary statements in the DSMs that the book is not to be used to answer legal questions, the DSMs are often used to answer legal questions.

14. Importance – 7 - a • 7. Society’s concept of mental illness, of normality. For example, conceptualized homosexuality as normal.--  1973, substituted “egodystonic homosexuality” for “homosexuality”--  1987, DSM-IIIR, abolished “egodystonic homosexuality” • -- Many DSM terms have become part of the American discourse, for example, “ADHD.”

15. Importance 7 - b • Alan Schatzberg, APA Presidential address, May 2010 called for “The general public, for example, read pop psychology articles or watch pop psychologists on TV and think they know a lot about emotions and feelings. Adding to this false sense of understanding is the common language used in psychiatric nosology.

16. Importance – 7 -c • “Other medical specialties have disorders based on Latin and Greek terms that are complemented by lay terminology or descriptors—take, for example, myocardial infarction and heart attack.

17. Importance – 7 - d • “When you look at psychiatry, you see disorders that are distinctly unmedical in sound in many ways—binge-eating disorder, major depression, panic disorder, etc., with no real parallel and more technical medical terminology.... We need to be more medical to be taken more seriously.”

18. Importance - 8 • 8. Defines psychiatry. While DSM-IV-TR has a 147 word definition of mental illness, which is not used, the aggregation of disorders in the DSMs tends to define psychiatry. However, the openness of DSM-IV’s NOSs, has created unclear boundaries as to “normal” and “illness.”

19. [Definition] Since medicine does not have a definition of “disorder,” or “illness,” or “disease.” Psychiatry should not feel a need, but, if presses, the following very unofficial definition of mental disorder might be adequate for some circumstances: Behavioral, emotional, cognitive, or conative symptoms that reach a clinically significant level of distress or disability.

20. Importance – 8a • DISORDERS OF INFANCY, CHILDHOOD, OR ADOLESCENCE NOT OTHERWISE SPECIFIED defined as “This category is a residual category for disorders with onset in infancy, childhood, or adolescence that do not meet criteria for any specific disorder in the Classification.” [WPS had a motion to correct this.]

21. Importance – 8 bPositive illusion - 1 • Nassir Ghaemi, 2011: • "Normal" non-depressed persons have what psychologists call "positive illusion"—that is, they possess a mildly high self-regard, a slightly inflated sense of how much they control the world around them.

22. Importance 8 – bPositive Illusion - 2 • Mildly depressed people, by contrast, tend to see the world more clearly, more as it is. In one classic study, subjects pressed a button and observed whether it turned on a green light, which was actually controlled by the researchers. Those who had no depressive symptoms consistently overestimated their control over the light; those who had some depressive symptoms realized they had little control.

23. Importance 8 - c“Diagnostic Combat”-1 • I've got a way with words that's slick.I'm sometimes troubled, you are sick.You are phobic, I'm just shy‹I'll explain the reason why.I am healthy, you are nuts;I'm quite normal, you're a putz.I can brandish words about;I can call you a dumb lout.

24. Importance – 8 – cDiagnostic Combat” - 2 • If you try to out-talk meI'll call that pathology.My advice? Concede defeat.No one can my verbiage beat. • Tom Greening • [Ethical issues for professionals]

25. Importance - 9 • Defines for what clinicians can be held accountable in terms of knowledge and skills. • [A happy hunting ground for test questions.]

26. Importance - 10 Defines responsibility for the public psychiatric sector. Defines reimbursibility for the private psychiatric sector. 

27. Importance - 11 While respecting the DSM, it is important not to worship the DSM

28. Fundamental - 1 • 1. To communicate [e.g., “bipolar disorder, mixed type“]

29. Fundamental - 2 To give the clinician and patient a tie to information as to cause, course and treatment.

30. Fundamentals - 3 To avoid stigmatizing the person with the illness, the environment, or the family [e.g., in the DSMs, almost no implications that inadequate parenting causes mental illness].

31. Fundamentals - 4 To provide coverage, that is, to have a term for all patients in psychiatric treatment.

32. Fundamentals – 5a To give the clinician and patient a tie to empirical information that: a. Provides a sense that the patient is not alone, that the patient signs and symptoms are tied to knowledge. [It increases the distraughtness for a patient to hear that their physician has no diagnosis for their condition.]

33. Fundamentals – 5 b • b. Provides a prediction as to: • i. Course [e.g., “Alzheimer’s is not reversible”] • ii. Treatment [e.g., “perphenazine is FDA approved for schizophrenia”] • c. May explicate the cause [e.g., “dementia due to Huntington’s disease”]

34. Fundamentals - 6 • Communicative validity. The definitions are to facilitate communications, to describe the disorder:            A] To the patient            B] To others working with the patient            C] To the profession in order to increase the knowledge about psychiatric illnesses, their treatment, and their prevention

35. Fundamentals - 7 • Treatment validity, part of predictive validity. Each treatment decision is a prediction.

36. Fundamentals To communicate Simplicity Constrictive Evaluate consensually

37. Fundamentals to treat • Complicated • Flexible • Evaluate empirically

38. DSM’s choice To focus on communicating, not on treatment.

39. DSM and Treatment • Kupfer, First and Regier:“With regard to treatment, lack of treatment specificity is the rule rather than the exception.”“The efficacy of many psychotropic medications cut across the DSM-defined categories. For example, the SSRIs have been demonstrated to be efficacious in a wide variety of disorders, described in many sections of DSM.”

40. Fluoxetine Uses Major depressive disorder* Obsessive-compulsive disorder* Premenstrual dysphoric disorder* Bulimia nervosa* Panic disorder* Bipolar Depression [combined with olanzapine]* Social anxiety disorder Posttraumatic stress disorder * = FDA approved

41. Chlorpromazine use - 1 1. Schizophrenia* 2. Nausea* 3. Vomiting* 4. Restlessness/apprehensiveness before surgery 5. Acute intermittent porphyria 6. Mania 7. Tetanus [adjunct]

42. Chlorpromazine uses - 2 8. Intractable hiccups* 9. Combativeness or explosive hyperactivity in children* 10. Impulsiveness, inattentiveness, aggressiveness, mood lability, and poor frustration tolerance in children* 11. Psychosis*

43. DSMs and validity - 1 • 1 - Event/environmental • 2 – stress/trauma,   3 - Genetic – e.g., Huntington’s.4 – Biological marker – e.g., polysomnography5 – Psychological test finding -- IQ

44. DSMs and Validities - 2 • Dx related to substances = 124 • Dx related to illnesses shared with the rest of medicine = 36 [obviously there are many more not mentioned in DSM-IV-TR] • Dx related to stress/trauma = 9

45. DSMs and validity - 3 • Dx related to season = 1 • Dx related to post-partum time = 1 • Total having some etiological elements, substances and somatic illnesses: 171 [about half of the DSM-IV-TR]

46. DSMs and Validity - 4 Prognosis – none in the DSM-IV-TR’s criteria sets. Although some criteria, through a retrospective approach, have attempted to build in some prognosis, for example, schizophrenia’s minimum six month requirement, and the six month limitation on adjustment disorders. [Also, the text of each Disorder in DSM-IV-TR has a section on course.]

47. As to prediction DSMs Provide a framework for prediction as to: • i. Course [e.g., “Alzheimer’s is not reversible”] • ii. Treatment [e.g., “perphenazine is FDA approved for schizophrenia”] • c. May explicate the cause [e.g., “dementia due to Huntington’s disease”]

48. Phenotypes • Phenotypes, the result of an interaction between a person’s genetic manifestations and their environment, may provide a classification that will avoid the difficulties of the infinite possibilities, but so far, no phenotype is part of psychiatric diagnosing.

49. Hx of DSMs • DSM-I – 1952 • DSM-II – 1968 • DSM-III – 1980 • DSM-IIIR – 1987 • DSM-IV – 1994 • DSM-IV-TR – 2000 • DSM-5 - 2013

50. ICDs International Classification of Diseases: ICD-I, 1893. ICD-9, 1977 ICD-9-CM changed annually, and will be used until September 30, 2013. ICD-10, 1994 ICD-10-CM, begins use 1 October 2013