NIMH Delivers a Kill shot to DSM-5

Science.Com
By Hank Campbell
May 3rd 2013

( NIMH is replacing the DSM http://www.nimh.nih.gov/research-funding/rdoc/index.shtml )

The National Institute of Mental Health (NIMH) is distancing itself from the the American Psychiatric Association and its upcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

While they acknowledge that the goal of DSM "is to provide a common language for describing psychopathology" they are no longer convinced that approach has value if we are going to solve 21st century neuroscience problems.  It is, paraphrasing the statement  of Thomas R. Insel, M.D., Director of the National Institute of Mental Health, more of a dictionary than a manual.  He uses the term "Bible" instead of 'manual' but I would have used 'glossary' rather than 'dictionary'.

Insel pulls no punches in his statement on why they are not going to fund things based on DSM criteria any more.

"The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure."

This is a charge leveled at psychology as well, and the field in general, but psychiatry takes the biggest hits, because they are supposed to be the most evidence-based. Unlike psychology, psychiatrists have to be M.D.s first. Writing in The New Yorker, Gary Greenberg tries to tackle why neuroscience hasn't kept pace with medicine, much less science, writing rather nicely that "it’s not entirely clear that psychiatrists want a solution to the problem."

Insel is more blunt. "DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever."

Basically, he says DSM is stuck in the past.

Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

Patients with mental disorders deserve better.

NIMH is leaving the past behind. In the past, Insel notes, they would reject a biomarker that did not match a DSM category. Now they instead want to collect how all data - genetic, imaging, physiologic and cognitive - cluster, and not just how symptoms do.  They call it the Research Domain Criteria (RDoC) project.

"That is why NIMH will be re-orienting its research away from DSM categories.," he wrote, and that means funding applicants are going to have to adjust to the 21st century.

The APA may be outraged, and certainly some DSM defenders, but I predict people in neuroscience who want to really do science and get NIMH funding are relieved that they are not going to have to cater to a document everyone seems to know was always flawed.

Let's Call the Whole Thing Off

Psychiatric Times
By Irwin Feinberg, MD
May27, 2010
Dr Feinberg is Professor of Psychiatry at the University of California at Davis

A vital consideration we learn in medicine is that continuing life support for a moribund patient past a certain point is harmful to the lives of all concerned. We have reached that point with DSM5. Dr Allen Frances has outlined compelling clinical arguments against many of the new disorders DSM5 proposes and he has shown how their adoption could have far-reaching, unintended, and damaging consequences for the patients we have pledged not to harm, and for society generally.

I write from the vantage point of 50 years of psychobiological research. Most of it is in the field of sleep neuroscience. However, as often happens in science, one thing leads to another and my observations enabled me to propose that the human brain undergoes a profound reorganization during adolescence driven by synaptic pruning and that some cases of schizophrenia might be caused by errors in this process.1 My association at NIMH with Edward V. Evarts, one of the great neurophysiologists of the last half century, stimulated me to propose that the hallucinations of schizophrenia result from a failure of feed-forward mechanisms that distinguish self-initiated neural activity from that produced by external stimulation, resulting in auditory hallucinations and other first-rank symptoms.

It is difficult and time-consuming to produce reliable new knowledge; it cannot be accomplished by committee fiat, as Drs Kupfer, Schatzberg and Regier seem to be believe. Dr Frances has mentioned the damage to psychiatric research that several new, ill-conceived categories in DSM5 could inflict. He also pointed out that changing nomenclature and diagnostic standards in the absence of compelling scientific justification will severely damage psychiatric research as well as clinical practice. Many of these changes would make it impossible to compare decades of epidemiological results with new findings. Moreover, the sloppy thinking and language in the proposed revision will be apparent to any educated layman. The “field trials” and timetables proposed for new categories are laughable to any statistically trained psychologist. The inevitable public exposure of the gross defects in DSM5 will bring our entire field into disrepute and diminish public support for the research we need.

There have been no research advances that demand new diagnoses and syndromes. Despite many intriguing findings, no psychiatric disease can be diagnosed by a biological or psychological test. If the DSM5 committee believes that new genetic or imaging findings justify a revised nomenclature, they should indicate which ones. Instead of creating dangerous new categories, let us discontinue DSM5 development and use its funding to make strong bridges between DSM-IV and ICD 11. We should also work to diminish or eliminate the huge differences between the US and the UK in the incidence of diagnoses like ADHD and pediatric bipolar disorders. These differences make it impossible to compare cross-national biological research on the same diagnostic categories, even in countries with similar cultures and medical traditions.

The proposed DSM5 would be a giant step backwards for psychiatry. American psychiatrists should petition the APA to drop this ill-conceived and badly executed project.

When mental disorders aren't

Boston Herald
Psychiatrist Allen Francis
Monday, March 22, 2010

As chairman of the task force that created the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which came out in 1994, I learned from painful experience how small changes in the definition of mental disorders can create huge, unintended consequences.

Our panel tried hard to be careful, but inadvertently contributed to three false “epidemics” - attention deficit disorder, autism and childhood bipolar disorder. Our net was cast too wide and captured many “patients” who might have been far better off never entering the mental health system.

The first draft of the next edition of the DSM, posted for comment last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This could create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day.

The manual, prepared by the American Psychiatric Association, is psychiatry’s only official way of deciding who has a “mental disorder” and who is “normal.” The quotes are necessary because this distinction is very hard to make at the fuzzy boundary between the two.

Where the DSM-vs.-normality boundary is drawn also influences insurance coverage, eligibility for disability and services, and legal status - to say nothing of stigma.

What are some of the most egregious invasions of normality suggested for DSM-V? “Binge eating disorder” is defined as one eating binge per week for three months. (I, along with more than 6 percent of the population, would qualify.) “Minor neurocognitive disorder” would capture many people with no more than the expected memory problems of aging. Grieving after the loss of a loved one could be misread as “major depression.” “Mixed anxiety depression” is defined by commonplace symptoms difficult to distinguish from the emotional pains of everyday life.

The recklessly expansive suggestions go on. “Attention deficit disorder” would become much more prevalent in adults, encouraging the already rampant use of stimulants. A category for temper could capture kids with normal tantrums.

The sexual disorders section is particularly adventurous. “Hypersexuality disorder” would bring great comfort to philanderers. “Paraphilic coercive disorder” introduces the dangerous idea that rapists merit a diagnosis of mental disorder if they get sexual excitement from raping.

Experts have an almost universal tendency to expand their own favorite disorders. This therapeutic zeal creates a huge blind spot to the great risks that come with unnecessary treatment.
Allen Frances is former chairman of psychiatry at Duke University.