Posts Tagged ‘ DSM-V ’

New article by Edward Shorter: “An Alternative, History-Based, Nosology for Psychiatry”

H-Madness is delighted to present a new piece by Prof. Dr. Edward Shorter, PhD FRSC, the Jason A Hannah Professor of the History of Medicine and Professor of Psychiatry, Faculty of Medicine, University of Toronto. Prof. Dr. Shorter has published widely on the history of psychiatry. His books include the classic A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (Wiley, 1997) and, most recently, How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown (Oxford,  2013). Here he explores the issue of psychiatric nosology, especially in view of the recent publication of the DSM-V.

An Alternative, History-Based, Nosology for Psychiatry

For their comments on earlier versions, the author would like to thank Tom Bolwig, Bernard Carroll, Max Fink, Gordon Parker, Robert Rubin, Michael Alan Taylor, and Lee Wachtel.

Current efforts to produce a classification of disease have not turned out well.  The fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) was released to general dismay in May 2013.  The current DSM, though vastly influenced by history, pays little attention to it, either in the form of attributing significance to patients’ own histories or in acknowledging the historical diagnostic traditions of psychiatry.

Yet it is possible to take history as our guide in drawing up classifications of diseases.  Here is an analogy: In Traditional Chinese Medicine a sifting process lasting thousands of years has taken place to winnow out effective medications from the ineffective ones lost in the mists of time.  Similarly in psychiatry, a winnowing process of mere tens and hundreds of years has distilled a good deal of the collective wisdom of the profession.  It is, in other words, possible to think about historical diagnoses as having the potential of cutting nature closer to the joints than do current diagnostic systems, drawn up on the basis of whim, fad, and consensus.[1]

There are, in disease classifications, lumpers and splitters. The DSM has taken splitting over the side of the cliff.  Philippe Pinel (1801) was the first lumper. The present effort at classification also is a lumping nosology that tries to discern diseases on the basis of biology and historical integrity. It is not meant to be absolutely inclusive of all psychiatric disorders but to convey some notion of how the main ones should be classified in a way that corresponds better than the present system to natural disease entities. In the absence of definitive biological verifications of many disorders, we have as our guide to “nature” the diagnostic traditions of a century and a half of scientific psychiatry, incubated in Germany and France, and brought today to great blossom in the transatlantic community.

Subsequent versions will need to come to grips with the addictions and the adult dementias.  Personality disorders have not been included.

An Alternative, History-Based, Nosology

 ADULT

I. Acute brief psychosis

II. Neuropsychiatric presentations (eg frontal and temporal dysrhythmia syndromes, Parkinsons, etc.)

III. Chronic psychosis: flat affect with avolition:

(a)—chronic psychosis:  hebephrenia

(b)—chronic psychosis: early progression to personality disintegration

IV. Chronic psychosis: Kraepelin’s disease.  (melancholic syndrome with or without mania; biological markers: DST, cortisol, sleep markers)  This includes such entities as vascular depression.   On a lifetime basis, one should rather think of “para-melancholia,” in which patients are at continuous risk of psychotic complications.

V. Chronic psychosis:  paranoia, meaning well-systematized delusional disorder, without  hallucinations, without disintegration of the personality.

VI. Catatonia.  It may also complicate any of these diseases (biological marker: immediate response to lorazepam)

VII. Non-melancholic, non-psychotic depressive and nervous illnesses

(a) mixed depression-anxiety  (Non-melancholic, non-atypical depression, often accompanied by anxious symptoms)

(b) atypical depression  (Note that this is distinct from the depression of what used to be called “bipolar disorder” and corresponds to the depressive disease described by William Sargant and Donald Klein.)

(c) OCD

(d) phobias

(e) paroxystic anxiety (“panic attacks”) (biological marker: various

panicogens)

VIII. Delirium

IX.  Breakdowns in the mind-body relationship

  X. CHILD

As adult, except for:

—Intellectual disability/learning disabilities

—Autism/catatonia with or without psychosis

—Hyperactivity syndromes (biological marker: abnormal EEG)

—The childhood anxiety disorders, including separation anxiety

Notes

II.  Neuropsychiatric presentations are not in DSM but should be.  There is widespread agreement among clinicians that epilepsy, for example, has its own psychiatric pathology.[2]   One senior American psychopathologist, Michael Alan Taylor, argues that psychiatry has erred seriously in omitting neuropsychiatric indications from the nosology[3], and this should be corrected.  We make an early start here with epilepsy and Parkinsons..

III.  This form of chronic psychosis splits the former “schizophrenia” into chronic psychotic disorders that partially remit, and those that do not.

(NB: positive symptoms may well be present, but they are not essential for the diagnosis of  chronic psychosis.)

“Schizophrenia” has been given here an overdue burial and replaced with several different forms of chronic psychosis that demolish the former firewall between psychosis and affect.  While abolishing the firewall, this nosology does restore the dividing line between “psychosis” and “neurosis,” although the latter term is shunned in favor of “nervous,” or the more modern-sounding but clunkier “non-melancholic, non-atypical depression. “

On the separation of hebephrenia from other forms of chronic psychosis:  hebephrenia does not carry a disastrous prognosis, even though there is no restitutio ad integrum.[4]   Hebephrenia is further distinguished by its onset in adolescence.[5]   In DSM-3 the hebephrenic subtype became the “disorganized type”; it was filled with catatonic symptoms, and was relentlessly progressive, none of which is true of Hecker’s original “hebephrenia.”   The DSM description also perpetuated the myth of the patients being “silly.”  Even though the subtypes have vanished from DSM-5, a disaggregation of “schizophrenia” is long overdue, and this represents a first step.

The term “personality disintegration” is used in the sense of W. Mayer-Gross et al (1954) in preference to the term “dementia.”[6]

IV.  On Kraepelin’s disease, meaning  “melancholic syndrome with or without mania,” this nosology basically restores the unity of Kraepelin’s “manic depressive illness” that he first formulated in the 6th edition of his textbook in 1899, bringing together all the various depressions, of whatever polarity, together with the manias, whether they occurred in the same illness episode or not.  This nosology follows the current of not considering mania and hypomania as separate illnesses[7]; nor are they part of “bipolar disorder,” as the DSM series presents it, because this version of affairs ignores bipolar disorder.

This nosology tackles head-on the issue of the “Kraepelinian dichotomy,” the firewall that Emil Kraepelin constructed between dementia praecox and manic-depressive illness in 1899.[8]  A fundamental issue in the classification of melancholia is whether it belongs under the psychoses or the non-psychoses.  The recent nosological tendency has been to consider psychotic melancholia (psychotic depression) as a rather anomalous subform of  melancholic disease, which, in general, does not involve delusions or hallucinations.[9]  In my view, this issue needs to be re-thought.  The lower boundary of “psychosis” needs to be pushed downward, beneath formal and systematized delusions, to include fixed ideas and highly eccentric notions. It is true that most melancholic patients do not have systematized delusions or hallucinations.  Still, in the words of Tom Bolwig, “They suffer from unjustified feelings of guilt, they don’t accept being ill, and they are unresponsive to all attempts at psychotherapy.  Isn’t that a deficiency in their reality testing, and thus a forme fruste of psychosis?” [10]

On a lifetime basis, psychosis may well be more common in melancholia than has been thought to date (a common assessment is 30 percent – yet the authors Michael Alan Taylor and Max Fink stipulate that an additional number of patients with forme fruste fixed ideas and delusive suspicions should be added on.[11]).  The percent of melancholics who on a lifetime basis may at some point or another be, or have been, psychotic is among the most difficult statistics to nail in the literature, because, as soon as a depressive patient becomes psychotic, the diagnosis is changed to “schizophrenia,” or “schizoaffective disorder.”  It is true that DSM accepts the category “psychotic depression,” but it is quite underused.    (There is also an ascertainment problem.  As one observer pointed out in 1970:  “It is well known that the more we like a patient, the less likely we are to place him on the psychotic end of the psychiatric spectrum.”[12] )

Many European authors considered melancholia basically a psychotic disorder.  As Wilhelm Griesinger noted in the influential second edition of his textbook in 1861, “The core of [the psychic depressive conditions] consists of the pathological prevalence of a distressing, depressive, negative affect.  . . . Corresponding to the mood there then appear false ideas and judgments that have no external basis, true delusions, distressing and painful in content.” [13]   Such authoritative statements continue into the present-day literature as well:  At a conference in 1991 Joseph Zubin  reflected, “Many outstanding diagnosticians first decide whether the patient before them has a psychosis, and then, after that decision is made, go on to determine whether it is schizophrenia or manic-depressive. . . .  Is it possible that what is the basic feature of the illness is psychosis, and that it takes the direction of either manic-depressive psychosis or schizophrenia depending on other factors . . . ?”[14]

In an effort to straddle this as yet unclarified issue of lifetime prevalence of psychosis in melancholic illness, the term “para” has been added to the lifetime version.

On the classification of melancholia, the disorder classically has been said to occur in two versions: (1) anxious, agitated (Angstmelancholie), and (2) stuporous (melancholic stupor).  There is no evidence that these represent separate diseases but are, rather, separate presentations.  There is a body of literature suggesting that psychotic anxiety exists as a separate diagnosis.[15][16]

In the spirit of Kraepelin, mania has been abolished as a separate disease and so there is no “bipolar disorder.”   It makes little sense to classify depressions on the basis of polarity, as the depression of bipolar disorder seems to be melancholic in nature, and identical to the melancholic version of unipolar depression (“major depression”).[17]  DSM-5 now accepts that bipolar and unipolar depression are identical, and calls both “major depression.”

“Major depression,” as well, has not found a place in this nosology on the grounds that it is highly heterogeneous, mixing together melancholic and non-melancholic illness.[18]

On the basis of etiology, there are many “depressions,” such as vascular depression, alcoholic depression, the depression of Parkinson’s, and so forth.  Yet it is unclear that any of these depressions have a distinctive psychopathology not included under either melancholia or non-psychotic nervous disease.  As science elaborates the existence of other distinctive depressions, these should be added to the nosology.   Bernard Carroll has raised a thoughtful objection to letting psychopathology drive the nosology:  “Aren’t you getting it backwards?  Our nosology requires distinctive disorders with distinctive etiologies.  The form of psychopathology is just one plank in the platform, not the main thing.”[19]  One can only respond that this view is indeed correct.  And if we were certain of the distinctive etiologies, we would, of course, let them drive the nosology.  But since we are not quite there yet, driving the nosology with psychopathology is a pis aller.

VII.  The classification of what used to be called “nervous disease” has bedeviled psychiatry for a century and a half, ranging through “nerves,” to “psychoneurosis,” to the current avalanche of micro-diagnoses.  The present nosology tries to lessen reliance on the term “depression,” which has been badly stretched out of shape by overuse.  It has also seemed judicious to revive the classic term “nervous disease,” as has ben recently suggested.[20]  The present version of the nosology seeks a compromise with the use of both terms, depression and nerves.

VII (a) Mixed depression-anxiety has been called “cothymia” by Peter Tyrer.[21]  It was the commonest form of depressive illness (with the exception of the psychoanalytic term “depressive neurosis”) in the decades before the appearance of DSM-3 in 1980, which sundered depression and anxiety.

VII (c-e)  There is no special line in the nosology for adult anxiety, or any of the DSM “anxiety disorders,”  several of which have now been shifted to the nervous category.

On removing OCD from the “anxiety disorders” as classified in DSM-4:  the present nosology argues that OCD be made a “nervous” disease, which simply means a non-psychotic, non-melancholic disorder the proper classification of which will have to await further research.  Patients with OCD do not display the classic somatic symptoms of anxiety, such as racing pulse, dizziness, sweating and tremor, nor the fear and dread of a panic attack.   Rather, the obsessive patient is uneasy and apprehensive about his or her symptoms, while fully recognizing that they are unjustified and unrealistic.

On the omission of PTSD from the nosology:  Traumatic neurosis was first described in the late 19th century, and belongs among the classic “nervous complaints.”  Patients who have experienced severe trauma, in wartime or otherwise, may indeed become symptomatic, but that their symptoms (“the full diagnostic criteria” in DSM terms) first occur after some unspecified duration — which is the essence of “post” — is not at all clear.  The whole diagnosis resulted from a systematic campaign of the Vietnam veterans in the late 1970s, and as a political construct PTSD has little place in a scientific classification of disease.

IX.  Breakdowns in the mind-body relationship:  There needs to be a category for what used to be called “hysteria,” “conversion disorder,” and so forth, symptoms that present in a medical way but are caused by the action of the mind.

Similarly, the personality disorders have been omitted from the nosology as they are considered a holdover from psychoanalysis and may well be abolished in ICD-11.

X.  The classification of childhood disorders poses a special conundrum, because “pure” anxiety without depression is commoner in children than in adults.   Children with “pure” depression more often present as angry.  In the adult section these issues are classified under “mixed depression-anxiety.”

It is now considered possible that hyperactivity has a biological EEG test. [22] This revives Charles Bradley’s original 1938 view of the EEG in hyperactivity.[23]

[1] Shorter E.  “The History of DSM,”  in Making the DSM-5: Concepts and Controversies, ed. Joel Paris and James Phillips.  New York: Springer, 201), 3–19, doi 10.1007/978-1-4614-6504-1_1

[2] Reynolds ED.  Trimble MR.  Epilepsy, psychiatry, and neurology.  Epilepsia, 50 (Suppl 3), 50-55, 2009.

[3] Taylor MA.  Hippocrates cried: the decline of American psychiatry.  New York: Oxford University Press, 2013.

[4] See Ilberg G.  Das Jugendirresein (Hebephrenie und Katatonie).  {Volkmann] Sammlung Klinischerr Vorträge, NF, nr. 67, 1287-1308, 1898. “ganz gut in der Lage, gewohnte Geschäfte zu besorgen.”  (1288)

[5] Taylor MA.  Shorter E. Vaidya NA.  Fink M. The failure of the schizophrenia concept and the argument for its replacement by hebephrenia: applying the medical model for disease recognition.  Acta Psychiatr Scand. 122, 173-183,  2010  doi: 10.1111/j.1600-0447.2010.01589.x.

[6] Mayer-Gross W.  Slater E.  Roth M.  Clinical Psychiatry.  London: Cassell, 1954, 262-264.

[7] Mayer-Gross W.  Slater E.  Roth M.  Clinical Psychiatry.  London: Cassell, 1954, 187f.

[8] Craddock N.  Owen MJ.  The beginning of the end for the Kraepelinian dichotomy.  British Journal of Psychiatry.  186: 364-366, 2005.

[9] Parker G.  Hadzi-Pavlovic D.  Melancholia: a disorder of movement and mood.  New York: Cambridge University Press, 1996.

[10] Bolwig personal communication, 22 July 2013.

[11] Taylor MA.  Fink M.   Melancholia: the diagnosis, pathophysiology, and treatment of depressive illness.  New York: Cambridge University Press, 2006, 16., 55.

[12] Jackson B.  The revised Diagnostic and Statistical Manual of the American Psychiatric Association.  American Journal of Psychiatry.  127: 65-73, 67, 1970.

[13] Griesinger W. Die Pathologie und Therapie der psychischen Krankheiten für Aerzte und Studirende, 2nd ed.  Berlin: Krabbe, 1861,  213.

[14] Zubin J. discussion comment, in Carroll BJ.  Psychopathology and neurobiology of manic-depressive disorders.  In Carroll BJ.  Barrett JE eds.  Psychopathology and the brain.  New York: Raven Press, 1991, 265-285, 283.

[15] Shorter E.  How everyone became depressed: the rise and fall of the nervous breakdown.  New York: Oxford University Press, 2013, 72-75.

[16] Stransky E.  Zur Lehre von der Amentia.  Journal für Psychologie und Neurologie. 6: 37-83, 155-191, 1906, see 163. “hochgradiger Angstparoxysmus.”

[17] Taylor MA.  Vaidya NA.  Descriptive psychopathology: the signs and symptoms of behavioral disorders.  New York: Cambridge University Press, 2009, 383.

[18] Parker G.  Beyond major depression.  Psychological Medicine.  35: 467-474. 2005.

[19] Bernard Carroll personal communication to Edward Shorter, 20 July 2013.

[20] Shorter E.  How everyone became depressed: the rise and fall of the nervous breakdown.  New York: Oxford University Press, 2013.

[21] Tyrer P.  The case for cothymia: mixed anxiety and depression as a single diagnosis.  British Journal of Psychiatry.  179, 191-193, 2001.

[22] Arns M. et al.  EEG phenotypes predict treatment outcome to stimulants in children with ADHD.  J Integrative Neurosci, 7, 421-438, 2008.

[23] Jasper HH.  Solomon P.  Bradley C.  Electroencephalograhic analyses of behavior problem children.  American Journal of Psychiatry, 95, 641-658, 1938.

For a more detailed bibliography of his work, click here.

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A MOMENT OF CRISIS IN THE HISTORY OF AMERICAN PSYCHIATRY

N.B. The DSM currently being constructed is referred to in this article both as DSM-V and DSM-5.  The APA at first used the appellation DSM-V, but later on began calling the document DSM-5.

Rarely has the medical world—and the general public, for that matter—been witness to an open drama such has taken place over the past two years in response to a medical association’s announcement that it was going to revise its diagnostic categories.  A war broke out with unlikely sides: Two former editors of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual (DSM) on the one side and, on the other, the officers of the APA and the leaders of the APA’s current Task Force that is revising the DSM.  Because of the Internet, the battle has been very public, and the APA has found itself on the defensive as it became repeatedly bombarded by open letters and columns in various media outlets.  These missives were immediately seized on by multiple bloggers.  The hallmark of the campaign by the former editors has been marked by unrelenting, inescapable repetition, which has added strength to their broadsides.

The scenario started simply and privately in April 2007, five years before the revised manual was scheduled for publication.  Robert Spitzer, the psychiatrist who had headed the  APA’s Task Force that revised the association’s third diagnostic manual in 1980 (DSM-III), dropped a two-line request to a colleague, Darrel Regier, Vice Chair of the Task Force that is currently updating the Association’s fifth manual (DSM-5).  Would it be possible for Regier to forward to him a copy of the minutes of the Task Force’s first two meetings?

Regier answered Spitzer quickly, saying summary minutes would be available to individuals like him for private use, but asking him to wait until the APA Board of Trustees formally approved the membership of the Task Force.  After an interval, having received no minutes, Spitzer renewed his request.  But nine months passed before Regier gave Spitzer a definitive answer in February 2008: Due to “unprecedented” circumstances, including “confidentiality in the development process,” David Kupfer, Chair of the Task Force, and Regier had decided the minutes would be available only to the Board of Trustees and the Task Force itself.  However, said Regier, the APA membership would be kept aware of DSM developments at professional meetings and through reports in various psychiatric publications.  But an article four months later in the Psychiatric News, the APA’s official news magazine, propelled Spitzer into public action.  We are now at June 2008, fourteen months after Spitzer’s original request.

In a letter to the editor, June 11, 2008, Spitzer began: “The June 6th issue of Psychiatric News brought the good news that the DSM-V process will be ‘complex but open.’”  And, he added, just a few weeks before, the outgoing president of the APA had stated that in the development of DSM-V the APA is committed to “transparency.” Then Spitzer expostulated:  “I found out how transparent and open the DSM-V process was when [Regier] informed me that he would not send me a copy of the minutes of DSM-V task force meetings . . . because the Board of Trustees believed it was important to ‘maintain DSM-V confidentially.’”  Spitzer then made available in his letter a paragraph from the Acceptance Form that all Task Force and Work Group members had signed stating that during their term of appointment and after, they would not “make accessible to anyone or use in any way any Confidential Information.” “Confidential Information” was defined in broad legal terms.

Spitzer continued: “I didn’t know whether to laugh or cry.  Laugh – because there is no way Task [F]orce and Work Group members can be made to refrain from discussing the developing DSM-V with their colleagues.  Cry – because” to revise a diagnostic manual in secrecy destroys the scientific process, “the very exchange of information that is prohibited by the confidentiality agreement.” Spitzer asserted that the making of DSM-III, III-R, and IV, by contrast, had been open processes where the widest exchange of information with all colleagues was encouraged.  Spitzer did not stop with this letter. Once galvanized into action, he began an unrelenting campaign against the “secrecy” of the fifth DSM revision process and urging “transparency,” soon forcing the APA to defend itself.  (Eventually, as I will discuss below, Spitzer was joined by Allen Frances, the editor of DSM-IV and its revision, DSM-IV-TR.  They were able to mount a highly visible battle by publishing their manifestos in a psychiatric news magazine independent of the APA, the Psychiatric Times.  Frances came to urge action on a wide variety of issues, publishing continual and frequent warnings of dire results if the APA leadership continued on the path it had chosen.  The latest as of this writing is centered around a critique of the “impossible complexity” of the new DSM-5 section on Personality Disorders.)

But before Frances joined the fray, Spitzer hammered on certain themes and charges tirelessly in a variety of publications spread over many months.  The repetition itself, rather than appearing redundant, added intensity to his challenges, which can be summarized as follows: (1) The DSM was being developed in secret because the Task Force and Working Group (specialty committees) members had had to sign confidentiality agreements.  (2) Revising a diagnostic manual behind closed doors defeats the very scientific process that is supposed to ensure the best possible scientific outcome.  (3) His repeated attempts, he charged, to get the DSM-V and APA leadership to explain their departure from the past policies that had been employed by the editors of DSM-III and IV, had brought forth answers that made little sense.  The leadership, Spitzer would often state, maintained that the working groups and Task Force needed privacy to freely discuss and candidly exchange views with others without worry that tentative views might be made public.  But, he asserted, it is unprecedented that distinguished researchers and clinicians would be reluctant to speak candidly, something they did openly all the time.  The APA had also argued that making minutes of meetings and conference calls would jeopardize the APA’s intellectual property rights, but it had not explained how this would happen. Finally, (4), the APA should return to the policy that the participants in the DSM  process be encouraged to interact freely with their colleagues and that summaries of DSM-V meetings and conference calls be made available to interested parties.  In addition to Spitzer’s concerns, other commentators began to question whether the participants in the DSM-V process had conflicts of interest because of ties to the pharmaceutical industry.

In vain did the APA and its supporters repeatedly–in public presentations, in postings online, and in written articles and letters–recount information about the history of the DSM-V revision process.  They pointed out that work had been going on since 1999, which in itself, they argued, showed the process was “open and inclusive.” As evidence they cited the publication of two volumes of white papers that, starting in 2002, discussed in detail the many psychiatric issues that would have to be addressed.  The APA also reported that it had publicly worked in conjunction with the World Health Organization (WHO) and the World Psychiatric Association to develop an NIMH conference grant application to review the research base for mental disorder diagnoses.  Several governmental organizations dealing with public health had subsequently joined this effort, and the five-year grant supported thirteen international conferences, which had produced over 100 scientific articles.  Many 100s of scientists and clinicians, it was emphasized, had been involved in these activities.  Such factual data from the APA, however, did little to stem the vigor of the attacks by Spitzer, and other critics became attracted.

Spitzer kept repeating his calls for “full transparency” and the posting of the minutes of all meetings and conference calls. “Anything less,” he stated, “is an invitation to critics of psychiatric diagnosis to raise questions about the scientific credibility of DSM-V.” [Spitzer post of Nov. 26, 2008] By early 2009, Spitzer’s campaign began to bring results, and the APA said it would post Task Force and Work Group reports (though not minutes) on the DSM-V web site, and it explained its vetting procedures to weed out those psychiatrists with excessive ties to pharmaceutical companies.  Also, spelling out what they had done already, the APA pointed out that the American Journal of Psychiatry had been steadily publishing editorials on a variety of DSM-V diagnostic issues.  The APA president again declared that the DSM-V process was more open than any previous process and that APA members as well as the public would have the opportunity to comment on the web site.  And in the Wall Street Journal Health Blog, under the heading “Psychiatrists Bash Back,” David Kupfer, the Chair of the DSM-V Task Force, was quoted as saying he wanted to set the record straight because “some of us have gotten . . . sick enough about playing defensive ball and being taken out of context.” The confidentiality clause, he explained, was not keeping the revision process secret but rather protecting, as the WSJ blogger wrote, “the intellectual property of the DSM . . . . The intention was to prevent someone involved in the process from, say, writing a book about his or her experience about the revision process prior to the DSM-V’s publication.”

This did not silence Spitzer.  He wrote again in the Psychiatric Times, repeating his usual arguments and now comparing the DSM-V process unfavorably to those of DSM-III and IV, accusing the DSM-V leadership of certain “restrictions on the appointment of advisors and consultants.” By contrast, he declared, during the making of DSM-III and IV, in order “to get the widest possible opportunity for input, essentially anyone interested in becoming an advisor was appointed.” Finally, he registered astonishment that Darrel Regier had stated that “DSM-V will be more etiologically based than DSM-IV,” proclaiming, “there is insufficient evidence to justify making the DSM more etiologically based.” (One of the crucial—and ultimately revolutionary– objectives of Spitzer’s DSM-III had been to make DSM diagnoses purely descriptive on the grounds that in psychiatry little is known about the etiology of mental disorders.)

At this point the APA decided to go on the offensive.  In a “Commentary,” “The Conceptual Development of DSM-V,” in the American Journal of Psychiatry in June 2009, four prominent officials and advocates of the DSM-V process laid out a lengthy essay that included the history of the DSMs, a presentation of psychiatric advances in recent years, and the authors’ plans for DSM-V.  Prominent were their statements that they were poised to carry out field trials and had decided that “one, if not the major difference between DSM-IV and DSM-V will be the more prominent use of dimensional [not purely categorical] measures in DSM-V”.  The authors of the Commentary, also traced specifically the intellectual origins of DSM-III and of the Research Diagnostic Criteria (RDC) that had preceded it, both of which had been under the leadership of Spitzer.   But the Commentary pointedly avoided mentioning his name.

At just this juncture, Allen Frances dramatically entered the fray.  He had stuck his toe in once, eight months previously, in a short editorial in the American Journal of Psychiatry, co-authored with someone else who also had already worked on the DSMs.  They told of a “mistake” that had been made in DSM-IV that had brought about “serious problems” in the diagnosing of sexual offenders, and they advised the DSM-V Task Force to beware the “unintended consequences of small changes.”   But now, in June 2009, Frances echoed the same theme in a lengthy and far-reaching article in the Psychiatric Times, warning, among numerous other caveats, that some of the proposed revisions for DSM-V might well produce more harm than good.  DSM-V, he predicted, was on the road to a “wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments—a bonanza for the pharmaceutical industry . . . .” As things stood now, the whole revision process was “badly off track” and could not meet its announced publication date of May 2012.  Not only did Frances echo many of Spitzer’s challenges, but he concluded by calling on the Board of Trustees of the APA to establish an external review committee to monitor the work on DSM-V.

The response of the APA, also in the Psychiatric Times, was swift.  Under the lead authorship of its president, it declared that Frances’ “factual errors and assumptions about the development of DSM-V . . . cannot go unchallenged.”  It took on Spitzer as well.  It repeated its position that “the process for developing DSM-V has been the most open and inclusive ever.”  It excoriated Frances for ad hominem attacks and defended the goals of DSM-V as against those of DSM-IV, which he had edited.  That revision, it said, had sought merely to mark time.  The APA hit out against the categorical diagnoses of DSM-III, fine for their time, but now “holding us back.”   Finally, it accused Spitzer and Frances of being motivated in their attacks on DSM-V by monetary considerations.  Both men, it was pointed out, stood to lose their royalty payments once DSM-V appeared and publications related to DSM-III and IV were no longer sold.

Spitzer answered the next day, on the “ugly turn” the debate had taken, with the APA’s claiming that his and Frances’ motivations in critiquing DSM-V were financial.  He seconded Frances’ assertion that a May 2012 publication date was chimerical.  Field tests were slated to start immediately, he pointed out, but no drafts of DSM-V had been made available. The public should be informed immediately “the specifics of where DSM-V is going.”

Within a few days—we’re now in early July 2009– Spitzer and Frances followed up with a bold open letter to the APA Board of Trustees.  DSM-V was headed for “disastrous unintended consequences,” they charged. “The rigid fortress mentality” of the DSM-V leadership meant it had “lost contact with the field . . . by sealing itself off from advice and criticism.” They warned that if DSM-V stayed on its path, increasing public controversy would arise, and the APA’s publishing monopoly of the DSM would come under scrutiny.  The Board of Trustees should “save DSM-V from itself before it is too late,” and Spitzer and Frances offered several recommendations that ought to be pursued.  (1) “Open the DSM-V process to full transparency.  Scrap all the confidentiality agreements.  Actively recruit a large circle of advisors.” (2)  Before field trials, there had to be input from individuals outside the Work Groups.  (3) Appoint an oversight committee that would monitor the DSM-V process.  (4) Make the publication date of the manual “flexible.”

A firestorm now erupted.  Both defenders and detractors of the APA weighed in.  The Psychiatric Times published retorts on almost a daily basis.  The bloggers were busy.  Daniel Carlat, a psychiatrist at the Tufts Medical School, wrote: “What began as a group of top scientists reviewing the research literature has degenerated into a dispute that puts the Hatfield-McCoy feud to shame.” The wider press began to report on the conflagration.  Of note, Christopher Lane, an avowed critic of the DSMs since 2007, accusing the APA of medicalizing normal states such as shyness, had a lengthy column on Slate summarizing the history of the controversy and supporting the attacks of Spitzer and Frances, his former bête noires.  The APA defended itself in its own Psychiatric News, disputing Spitzer and Frances, and responded to their accusations “point by point.”

Throughout the summer and fall, Frances published steadily in the Psychiatric Times, plus once in the British Journal of Psychiatry.  By December 3, 2009, he was claiming victory in yet another Psychiatric Times article.  He cited “anonymous sources” from whom he had learned that within a month or two, the APA would post a draft version of DSM-V and tshen allow an additional month for comments.  The same sources, he went on, had informed him that a new timeline was about to be announced that would have field trials following—not before–the period of receiving comments and would push back the date of publication of DSM-V one year to May 2013.  Frances pointed out that only “external pressure” had brought about these “improvements” which also included the APA’s Board of Trustees appointing an oversight committee to monitor the work on DSM-V.  He concluded by urging the “research community” as well to apply pressure for continued caution by the DSM leadership.  The APA, he suggested somewhat ominously, would be “exquisitely sensitive” to researchers’ pressure since it needed their support if it wished to keep the “franchise” to continue to publish the DSMs.

The APA showed that it was ready to bow to the inevitable by giving Frances space in its American Journal of Psychiatry to publish a short editorial, “The Limitations of Field Trials: A Lesson from DSM-IV.” And on December 10, the APA issued a press release announcing that they were extending the date of publication of DSM-5 a year, until May 2013.   (This is the point at which the APA seems to have shifted from calling the new manual “DSM-V” to “DSM-5,” as if to show that the revision signified a departure from the “old” DSM-III and IV.)  To cover over an embarrassing situation, the President of the APA bravely declared this lengthening of the timeline would allow “more time for public review, field trials, and revisions.” The press release gave as an additional reason for the time extension that it would allow the APA to better cooperate with WHO as it worked to release its next revision of the International Classification of Diseases (ICD) due out in 2014.

Two months later, on February 10, 2010, the APA posted the DSM-5 draft online (www.dsm5.org) and declared it would accept public comments until April 20.  The day after the draft appeared, Frances and Spitzer (although in later postings Spitzer’s name no longer appeared) joined forces to publish in the Psychiatric Times “Opening Pandora’s Box: The 19 Worst Suggestions for DSM5.” (http://www.psychiatrictimes.com/print/article/10168/1522341?printable=true)  Obviously, they had not composed this lengthy broadside on “Problematic New Diagnoses” overnight.  And not surprisingly, their article did not end just with their critique but with five new suggestions to the APA’s Oversight Committee advocating: extending the time allowed for public review; careful editing “of each word; ”public review of the field trial methods; establishing three Oversight subcommittees to monitor “forensic review, risk benefit analysis, and field trials;” and posting the plans for cooperation with WHO.

The public revelation of the DSM-5 draft triggered immediate reaction from the print and Internet media as well as from the blogosphere reporting on the history of the two-year controversy that had surrounded the revision of the manual and analyzing the draft itself.  Public advocacy groups that had been campaigning for their own wishes for or against the inclusion of certain diagnoses sent out bulletins to their members.  Well known commentators like George Will were recruited by major newspapers (in this case the Washington Post) to give their opinions.  NPR had a half-hour broadcast, including an interview with David Kupfer and questions and comments from the audience. The online news outlets were numerous, among the major of them: Huffington Post, MedPage Today, abcNews, AP, Psychology Today, PsychologyOnLine, University of Chicago Medical Center (Science Life Blog), YouTube, and PsychCentral.  The print publications included The Economist, Science, New Scientist, TIME, the  New York Times, Wall Street Journal, Washington Post, Los Angeles Times and USA TODAY.

*************************

Within three weeks of the APA press release, Frances returned to pressing his cause, sometimes every other day, not only in the Psychiatric Times, but in latimes.com, British Medical Journal, Psychology Today, and the Journal of the American Academy of Psychiatry and Law.  In a five day span, in the middle of March, he warned against DSM-5’s worsening the “epidemic” of ADD (Attention Deficit Disorder), attacked the new diagnoses proposed by the Sexual Disorders Work Group, and argued against the medicalizing of normal grief.  He continues to this moment.

A few observations seem in order:

The APA leadership was slow to assess and respond to the strong voices and skillful arguments of Robert Spitzer and Allen Frances and has learned a bitter lesson about the adroit use of the Internet.

The role of the Internet in popularizing and spreading the arguments and charges made by Robert Spitzer and Allen Frances cannot be overstated.  Without the Internet, the ease and rapidity of their frequent attacks and challenges would have been impossible.  It is worth repeating the trite observation that the Internet is the printing press of the 21st century, well adapted to fomenting upheavals.

I have not documented the innumerable blogs the many lay advocacy groups sent to their members nor the fervid online discussions of controversial matters by the public at large.  Examples of the latter would be the proposed autism spectrum under which Asperger’s Syndrome would be subsumed or the wished for inclusion in DSM-5, by scores of divorced fathers, of the diagnosis of Parental Alienation Syndrome.  The attempt by the public to weigh in on scientific decisions is here to stay.  The only question remaining is how scientific and medical groups are going to react to ever-louder lay voices which will only increase as they are facilitated by Facebook and Twitter or other social and professional networking sites.

The Psychiatric Times, founded 18 years after the APA’s Psychiatric News, has profited greatly as a result of its being the main vehicle by which the two former DSM editors circulated their views.  This print and online news magazine has perhaps catapulted itself into being the leading news source in American psychiatry.

It is too soon for accurate and coherent public discussion of internal events in the APA that brought about its seeming capitulation.  This is, however, a story impatiently awaited by the thousands of readers who followed its unfolding.  A knowledgeable and full exploration of Allen Frances’s ongoing intense critiques of the making of DSM-5 may take longer.

It has been speculated by some that the much-discussed Confidentiality Agreement was designed especially to prevent Task Force and Work Group members from publish anything about DSM-5 unless it was through APPI—the APA’s publishing arm which provides the APA with millions of dollars of additional revenue.

The greatest curiosity attaches itself to events yet to unfold as the revision process of DSM-5 goes on.  There are many who hope to hear more from the official leadership of the Manual and the APA itself than has been the case up to now.  However, Allen Frances’ contribution will not diminish if he has anything to say about it.

Hannah S. Decker

To read the other posts on the DSM-V, click here.

2010
04/27
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DSM-V: Continuing the Confusion about Aging, Alzheimer’s and Dementia

Since the early twentieth century, when Alois Alzheimer and Emil Kraepelin constructed it as a unified clinical-pathological entity, Alzheimer’s disease has been both one of the most stable and one of the most problematic neuropsychiatric entities.

Alzheimer’s (listed as Dementia of the Alzheimer’s Type in DSM-IV) remains one of the very few instances in which psychiatry has managed to associate a well-defined clinical syndrome – global deterioration of cognitive ability – with clear-cut brain pathology – the senile plaques and neurofibrillary tangles that continue to be regarded as the essential biomarkers of the disease.

And yet it has been one the most problematic of disease entities because – despite the relative clarity around its clinical symptoms and pathological correlates – a clear boundary has not been established between Alzheimer’s and aging. The cognitive deterioration that defines Alzheimer’s and other forms of dementia is experienced by everyone as they age, though to a much lesser degree in people not diagnosed. Similarly, decades of accumulated autopsy evidence has demonstrated that the plaques, tangles and all other putative biomarkers for Alzheimer’s and other major forms of dementia are found to varying degrees in all aging brains.

Thus on evidentiary grounds, at least as good a case can be made for viewing Alzheimer’s as an endpoint on a spectrum of cognitive changes associated with normal aging as for viewing it as a disease. But for political reasons, since the 1970s psychiatrists, neurologists, and Alzheimer’s advocates in the United States and Europe, have overwhelmingly asserted that it should be regarded as a disease. These political reasons can be summed up succinctly: government funds research for dread disease, not for discovering the fountain of youth. And as a political construct, Alzheimer’s as dread disease has been wonderfully successful at winning federal funding for research.

But critics – most notably neuroscientist Peter Whitehouse and anthropologist Daniel George in the their book The Myth of Alzheimer’s, have argued that the Alzheimer’s disease construct represents the medicalization of brain aging and profoundly exacerbates the stigmatization of age-associated cognitive decline.

To no one’s surprise, the draft of DSM-V does not back off of the commitment to viewing Alzheimer’s and similar conditions as disease entities distinct from aging. But it does propose two significant changes that, while well-intentioned, may greatly extend the medicalization of aging and worsen the stigma of age-associated cognitive decline.

Perhaps the most dramatic change related to these conditions in the draft DSM-V is the proposal to drop the term “Dementia” and replace it with the term “Major Neurocognitive Disorder.” The stated rationale for the proposed change mostly focuses on nosological considerations that seem on the whole sensible to address. But interestingly, the rationale also notes that the term dementia has “acquired a pejorative or stigmatizing connotation.” For just this reason, even critics of the Alzheimer’s disease construct seem to be welcoming this proposed change (for example, see the comments to the Myth of Alzheimer’s blog post on DSM-V changes.)

I am less optimistic that the ostensibly more neutral language of neurocognitive disorder will significantly lessen the stigma associated with Alzheimer’s disease or the milder cognitive impairments associated with aging. To be sure, the label dementia is deeply stigmatizing. But its stigmatizing power comes not from the word itself but from a deeper cultural impulse of marginalization. As long as we judge the worth of human beings by normative standards of productivity and competence, any label used to denote an impairment that prevents an individual from meeting those standards will soon enough come to be stigmatizing. Absent any meaningful attempt to change the normative standards that drive the stigmatization of aging and cognitive impairment, changes in terminology will not be de-stigmatizing but merely euphemistic. To the degree that the deployment of euphemism allows us to ignore unpleasant realities and shirk difficult social and cultural work, it will do more harm than good.

The other major change related to age-associated cognitive deterioration in the draft DSM-V is the proposal to add the category “Minor Neurocognitive Disorder” to recognize “the substantial clinical needs of individuals who have mild cognitive deficits in one or more of the same domains but can function independently… often through increased effort or compensatory strategies.”

The creation of the “Minor Neurocognitive Disorder” is an especially worrisome example of what, in a post to h-madness a couple of days back, Allan Horwitz characterized as a “Trojan horse that would diagnose nearly a-symptomatic people as being in the early stages of a disorder.” While such early diagnosis and treatment might be a well-intentioned effort to make help available early on, or to enhance investigation of the causes of a disorder, it has clear potential for abuse by a pharmaceutical industry eager to expand the market for their goods. This potential can be seen in the stated rationale for the proposal, which notes that early recognition of

“Mild Cognitive Impairment may be particularly critical, as it may be a focus of early intervention. Early intervention efforts may enable the use of treatments that are not effective at more severe levels of impairment and/or neuronal damage, and, in the case of neurodegenerative disease, may enable a clinical trial to prevent or slow progression.”

This is a fairly transparent statement of the hope that the drugs found to be of dubious value to patients diagnosed with Alzheimer’s disease might be found to offer greater benefit to patients in prodromal stages – or at least to generate more profits for drug companies.

The proposed diagnostic criteria for Alzheimer Subtype of Major or Minor Neurocognitive Disorders in the draft DSM-V stops just short of endorsing Mild Cognitive Impairment (MCI) as a prodrome of Alzheimer’s disease. The stated rationale for the proposal notes that research is ambiguous. Patients with MCI in memory disorder clinics have been shown to progress to Alzheimer’s at a rate of 12-15% per year, but population-based studies show a much lower rate of progression, with some individuals actually improving. Thus, the predictive value of MCI (or what under DSM-V will be called Minor Neurocognitive Disorder with Memory Impairment) does not warrant an automatic diagnosis as prodromal Alzheimer’s disease. The diagnostic criteria require not only evidence of mild memory impairment, but “clear supporting evidence for the Alzheimer etiology (e.g., a positive test for a known mutation in an Alzheimer’s disease associated gene), or with evolving research, documentation based on biomarkers or imaging.”

A positive test for one of the Alzheimer’s genes is a high diagnostic hurdle that would function to prevent dramatic inflation of this diagnostic category, but given the value to many powerful interests of very early Alzheimer’s diagnosis, who can doubt that progress in biomarkers and imaging will be quickly forthcoming? Smart money should be investing in pharmaceutical companies that stand to tremendously enlarge the market for drugs that have proven to be of dubious value for people diagnosed with Alzheimer’s.

And once every senior moment is diagnosable, we really will have reached the point – as Horwitz right worries – of pathologizing everyone.

Jesse Ballenger

This post can also be find on Alt(z)heimer

2010
03/19
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Du « facteur de risque » au « risque de psychose » : focus sur la schizophrénie dans l’esquisse du DSM-V

Le comité de rédaction du manuel de psychiatrie américain (Diagnostic and Statistical Manual of Mental Disorders) a réussi à créer le buzz sur Internet en dévoilant le mois dernier l’avant-projet de la cinquième édition, annoncée pour 2013. Ce manuel est l’objet d’une attention particulière parce qu’il sert de référence aux compagnies d’assurance américaines, mais aussi aux publications scientifiques internationales. À ce titre, il s’est imposé à tous, non pas en créant le consensus, mais en offrant des données standardisées, qui construisent la condition de possibilité d’une mise en commun de données hétérogènes, même si personne ne s’accorde sur l’interprétation psychopathologique à leur donner. Quelle est la grande nouveauté du DSM-V ? Une approche dimensionnelle des troubles mentaux, selon les méthodes de la psychologie cognitive. En clair, il s’agit d’abandonner les catégories discontinues, pour passer à une conception définie à partir d’échelles qui mesurent le comportement et qui peuvent faire l’objet de calculs de corrélation. Le but visé est d’établir des variations par rapport à la norme et des liens transversaux entre les troubles mentaux.

L’approche dimensionnelle du DSM-V doit réduire la comorbidité excessive que l’on trouve dans les diagnostics actuels, nous dit-on dans l’argument. Mais d’autres modifications sont attendues, notamment en ce qui concerne la schizophrénie. Il faut rappeler que la schizophrénie est une représentation de la maladie mentale propre au XXe siècle : ce n’est pas une entité clinique typique, c’est un regroupement nosologique de formes cliniques disparates, mis en ordre naguère sous le terme de démence précoce par Kraepelin, puis par Bleuler (Dementia praecox oder die Gruppe des Schizophrenien, 1911), à partir des mécanismes freudiens. Plusieurs types de psychose schizophrénique sont classiquement décrits : la schizophrénie simple, l’hébéphrénie, la catatonie et la démence paranoïde. La première forme a connu une fortune considérable : reformulée par Kretschmer comme une forme latente et non évoluée (schizoïdie), elle permet de considérer tout un continuum d’états bizarres ou franchement pathologiques, en regroupant des formes discrètes de folie. Une fois réunis dans une même entité, ces troubles de gravité variable se prêtent plus facilement aux analyses psychologiques dynamiques, et globalement la schizophrénie s’est imposée au siècle dernier comme l’expression d’une modernité dans le champ de la psychiatrie. À titre de comparaison, on peut dire qu’elle a pris la forme d’un phénomène socio-culturel aussi important que l’hystérie à la fin du XIXe siècle, mais sur un plan international, et qu’elle est une représentation bien connue du grand public, notamment grâce à la littérature et au cinéma américains. Après-guerre, la schizophrénie a concentré les essais thérapeutiques, encouragés par la découverte du premier neuroleptique (chlorpromazine, 1952), mais aussi par la diffusion des psychothérapies. Depuis les années 1980 (DSM-III) le manuel américain a abandonné la référence à la psychanalyse et se contente de répertorier cinq formes de schizophrénie, sans interprétation psychopathologique : type désorganisé, type catatonique, type paranoïde, type indifférencié et type résiduel. Désormais le DSM-V rompt avec ce modèle catégoriel : les frontières entre les sous-catégories sont abolies au profit des dimensions, et deux syndromes reconfigurent la schizophrénie, en renforçant le pôle de la schizophrénie simple, débutante ou non évoluée : la catatonie est séparée de la schizophrénie et un nouveau syndrome de risque de psychose est avancé.

Premier point : la catatonie est une ancienne catégorie qui désigne une inertie motrice et un repli sur soi (tant comportemental que psychique), décrite par Kahlbaum en 1874. Néanmoins ce trouble est devenu plus rare sous sa forme déficitaire grave, il peut se rencontrer au cours d’autres troubles comme la mélancolie et il répond favorablement à certains médicaments anxiolytiques. En résumé, séparer la catatonie de la schizophrénie est un geste de rupture fort par rapport à l’héritage de la psychiatrie classique depuis plus d’un siècle – mais cela n’aura pas une grande incidence sur la pratique psychiatrique quotidienne, d’autant plus que le DSM-V permettra toujours de diagnostiquer une schizophrénie avec une forte dimension catatonique.

L’autre point passe pour une innovation : l’avant-projet du DSM-V a créé un effet d’annonce en dévoilant une nouvelle entité, le syndrome de risque de psychose (Psychosis Risk Syndrome) et en incitant le public à s’exprimer sur sa validité, en l’état actuel des connaissances et des pratiques de prévention de la schizophrénie débutante, qui laissent les spécialistes partagés (les traitements étant lourds, invalidants et stigmatisants). D’autres modifications du diagnostic de schizophrénie sont à l’étude, comme la recommandation d’abandonner la catégorie de trouble schizo-affectif. Là encore, les nouvelles évaluations dimensionnelles permettront d’établir un lien sous la forme d’une schizophrénie avec une forte dimension de l’humeur.

Que penser de cette reconfiguration de la schizophrénie ? Au premier abord, elle abrase son image déficitaire, la schizophrénie étant séparée de la catatonie et renforcée au niveau de son spectre de variation à la norme, par une évalution de la schizophrénie débutante en tant que facteur de risque de psychose. D’un point de vue historique, l’évolution du DSM est-elle révolutionnaire ? Certes non sur le plan méthodologique, l’approche dimensionnelle de la personnalité est un programme de recherche bien établi de la psychologie cognitive depuis plus de vingt ans. Je propose ici une autre piste de réflexion : l’évolution de la psychiatrie vers une gestion des risques, telle que le sociologue Robert Castel (La Gestion des risques. De l’anti-psychiatrie à l’après-psychanalyse, 1981) l’avait analysée, connaît peut-être ici une nouvelle étape, en subordonnant la schizophrénie débutante aux catégories usuelles de l’épidémiologie. En effet, le syndrome de risque de psychose ressemble à s’y méprendre à l’application directe des facteurs de risques épidémiologiques dans un manuel clinique.

Emmanuel Delille


2010
03/18
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DSM-5 – or what are you and were they thinking?

The original DSM series was motivated by an attempt to correlate several conflicting classification schemata (such as still persist in the ICD).  However, since the American Psychiatric Association was taken over by a set of narrow specialists in neurobiology in the 1940s (Kirk and Hutchins) it has become an ever more inflexible instrument.  In general – with a few notable exceptions such as the grudging acceptance of homosexuality as normal behavior (the topic of a brilliant episode of This American Life) – each edition has been worse than the last.  The new edition promises to continue this proud trend.

Before going into some particular changes for this edition, let me rehearse two problems with the entire set.   A significant logical flaw is that it is entirely self-fulfilling: psychiatrists, psychologists and patients can only get re-imbursements for sessions attached to a specific DSM diagnosis.  There can be no disagreement with the code, even if the whole is largely flawed.  In my own experience and that of my friends, this generally means that we sit down with our psychiatrist during a session and choose a code which will do relatively little professional damage if it gets out, and will provide the drugs that she and I prefer.  I know a large number of psychologists and some psychiatrists (the non-pill-pushing variety) who find this a tad abhorrent.  Further, and again I’ll speak for myself as patient, I find the current set of available conditions massively restricting. When going through what your average Australian would call a ‘rough spot’ several years back, I was offered variously diagnoses of depression, hypermania, hypomania, manic depression, ADHD, anxiety, hyperthyroidism and anhedonism – I deeply prefer the nineteenth century offerings of melancholic, bustling, a delicate sort: each with their own social acceptance and romantic overtones. Bateson’s definition of information (a difference which makes a difference) does not obtain here, since most ascriptions of these classifications lead to the prescription of a very small set of drugs.

I am feeling ever more constrained to always keep my behavior within acceptable limits.   In the nineteenth century I could, in my Sherlock Holmes persona – but maybe I’d better not talk about that one –  fall into a black depression, shoot up some cocaine and play the violin then come out of my funk and rid the world of Moriarity.  Today, that archcriminal would quickly get me hospitalized.  In short, the medicalization of deviance – a term first deployed in the 1970s – is in its heyday.   Where the United States still manages to see itself as a haven for liberty,  I wonder how one can maintain that rosy façade in the face of the medicalization of the minds of most of our population and the largest incarceration and execution rate (the only really competing paradigm in the United States to DSM is mortal sinners vs nice people) in the developed world.

Enough of a rant perhaps.  Let’s take as given a tradition of not recognizing social, communal and family dimensions of difficult internal lives of citizens. I find it hard to be truly beatific in a world bent on ecological self-destruction and living in a society bent on unjust wars and providing no safety net for its poorest citizens so that many die unnecessarily, but I guess that’s my fault. It’s sad, but fortunately I have some happy pills.

I actually rather like the potential dissolution of Asperger’s syndrome into Autism Spectrum Disorder – despite the shocked reaction of parents of some computer geeks, who are often characterized by some forms of behavior associated with Asperger’s (just visit the Google campus for a day to verify this).  These are clearly part of a package of behaviors which run the full gamut from what should be considered normal to that which is definitely problematic.  If I had a general theory of what is called mental illness I would take this principle as a baseline: it’s spectrums all the way down.  That’s what multidimensionality is all about.  I do find some fault with Susan Swebo’s report though – what exactly does it mean to cleave to a principle that collapses without disambiguating:

“How to address Pervasive Developmental Disorders – Not Otherwise Specified (PDD-NOS). The individuals currently diagnosed with PDD-NOS may still be described in DSM-V, but the work group will discuss whether they can redefine ASD in such a way that the PDD-NOS diagnosis isn’t necessary, as this diagnosis currently captures a very heterogeneous group of individuals.“

If I understand the logic of this (though I’m getting depressed as I write so please don’t pay any attention to me), this means that a heterogeneous group of individuals  will become homogeneous (which basically means treated by the same drugs) if we wiggle the definition of ASD.  And this is seen as a breakthrough rather than sweeping interesting problem cases under an available carpet?

I am not totally negative about this revision.  Indeed,   I close on a somewhat hopeful note.  There are revisions being suggested to the definition of just what a mental disorder is, which include:

“C    Must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals)

D. That reflects an underlying psychobiological dysfunction

E. That is not primarily a result of social deviance or conflicts with society“

If in practice we really honored C and E and defined D in some useful way (which would have to go way beyond psychobiological) then we might work towards a socially useful and culturally rich treatment of mental disorders.   First, though, the psychiatric community needs to come up with rich treatments of C and E, since currently childhood deviance or conflict is not seen in this way (even though it’s of the nature of adolescence) and the set of ‘common stressors’ and ‘culturally sanctioned’ do not include living in an overcrowded world (which we know, through rigorous study,  causes problems for rats).

Geoffrey C. Bowker

2010
03/17
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DSM V et dérives de la démocratie : quelques observations d’un clinicien inquiet

La mise en ligne des développements de la future cinquième version du célèbre manuel constitue un événement scientifique d’ampleur méritant que l’on s’y attarde parce qu’il est un observatoire heuristique d’une psychiatrisation de la vie sociale, comme la montré Lane (2009). Une brève visite du site construit par l’APA permet de se faire une idée de ce que seront les changements par rapport au DSM IV. Il m’est ici impossible de les examiner dans leur entièreté et avec la rigueur qui s’imposerait idéalement, c’est pourquoi je me centrerai sur lesdites « paraphilies » – soit littéralement les « manières d’aimer à côté » – que je connais mieux et qui me semblent paradigmatiques dans la mesure où la captation psychiatrique de la sexualité à travers le DSM pose une série de problèmes intéressants pour le chercheur en sciences humaines cliniques. Avant de m’intéresser aux paraphilies, je voudrais souligner que le terme « paraphilie » a remplacé celui de « perversion », ainsi que cela a été le cas d’autres termes comme celui de « névrose » en ce qu’ils émanaient du corpus psychanalytique. En changeant de terme, les concepteurs du manuel évacuent les débats d’école – pourtant riches et féconds – au nom du consensus politique auquel ils se sont promis d’aboutir coûte que coûte. On sait que ces mutations terminologiques traduisent l’élimination progressive des lexiques psychanalytiques, opération renvoyant à la recherche d’une légitimation d’une psychiatrie en mal de repères contre la psychanalyse (Blondiaux, 2009).

Avant d’examiner plus avant le sort réservé aux paraphilies, il me faut encore introduire une remarque substantielle sur la question de la démocratisation apparente et affichée de l’élaboration du manuel puisque tout un chacun est aujourd’hui invité à faire des commentaires sur le site web du DSM V, qu’il soit clinicien, chercheur, administrateur, malade ou parent de malade. Il est immédiatement possible d’interpréter cette offre comme relevant d’une vaste manœuvre de marketing qu’on ne pourrait manquer de relier à la rhétorique sous-jacente à l’élaboration du manuel (Kirk & Kutchins, 1998). Cette ouverture au public profane ou initié nourrit l’illusion d’une participation active à la conception d’un instrument qui les concerne : comment ne pas y voir une entrée de plus dans la psychiatrisation de la vie privée ? Les concepteurs vont-ils tenir compte des commentaires et, si oui, comment ? Se pose, selon moi, la question de la méthode et de son contrôle, à supposer bien sûr que la bonne foi accompagne l’élaboration du manuel. Et si les « feed-back » étaient effectivement considérés, seront-ils hiérarchisés ? Le commentaire d’un malade ou d’un parent a-t-il la même valeur que celui d’un chercheur ou d’un directeur d’institution psychiatrique ? Il me semble que ces questions témoignent d’une dérive de la démocratie, qu’on peut appeler le « démocratisme » (Lebrun, 2007), soit la propension de nos sociétés à développer un principe de symétrie dans le sens où tout se vaut, tout le monde a le droit au débat indépendamment de sa position dans le champ ; en quelque sorte chacun est « expert » et les différences interindividuelles ou intra-individuelles se voient lissées par une référence à l’égalitarisme juridique. De manière plus radicale, le problème de la rupture épistémologique entre sens commun et sens scientifique se pose ici avec une acuité singulière. Si la science n’est que la traduction savante du sens commun, alors elle ne mérite plus, à mes yeux, le statut de science au sens où elle devrait pouvoir développer un méta-langage susceptible d’éclairer autrement les phénomènes de sens commun.

Dans le registre des paraphilies, faisant partie des troubles sexuels et de l’identité de genre, les concepteurs de la nouvelle version réintroduisent le « trouble paraphilique coercitif » (Paraphilic Coercive Disorder) qui avait été proposé lors des précédentes révisions mais n’avait pas été adopté. Cette nouvelle entité a été proposée comme « syndrome distinct », séparé du trouble sadique sexuel (le diagnostic de trouble paraphilique coercitif exclut celui de sadisme). On parle de trouble paraphilique coercitif lorsque la personne est affligée ou détériorée par ses attirances ou a cherché la stimulation sexuelle en forçant la relation sexuelle sur trois personnes ou plus non consentantes dans des occasions séparées (je ne peux ici m’exprimer sur cette définition hautement problématique). Par le truchement de la référence au consentement, c’est le viol d’un point de vue légal qui paraît visé ainsi que semblent le confirmer les notes complémentaires faisant état de travaux menés sur des populations judiciarisées (en particulier des violeurs). On ne peut manquer de souligner l’infiltration des catégories juridiques dans le diagnostic psychiatrique aboutissant in fine à une classification hybride. De mon point de vue, la non-distinction comme l’absence d’autonomie entre les catégories juridiques et les catégories psychiatriques est non seulement une erreur épistémologique mais un véritable vecteur d’une pénalisation-psychiatrisation des populations, à grande échelle.

Cet ajout s’éclaire encore d’une autre lumière lorsqu’on le relie aux deux changements majeurs portant sur les paraphilies, lesquels affecteront le diagnostic. Il s’agit, d’une part, de l’introduction du terme « trouble paraphilique » et, d’autre part, de l’indication du nombre de victimes dont je ne traiterai pas ici. Le premier grand changement renvoie à la distinction posée entre constat d’une « paraphilie » et diagnostic d’un « trouble paraphilique ». En effet, les paraphilies ne sont pas ipso facto considérées comme des troubles psychiatriques. Une paraphilie ne réclame donc pas nécessairement une intervention psychiatrique. Est-ce l’aveu implicite que les constats pourront être posés par le quidam dans le sens d’une démocratisation des usages du DSM alors que le diagnostic ne le serait que par le clinicien ? Une définition du trouble paraphilique est donnée : ce qui cause une détresse ou une diminution de l’individu ou ce qui menace les autres. C’est donc au psychiatre de faire la part en ce qui sera un trouble et ce qui n’en sera pas un sur base d’une définition qui n’apporte que peu d’éléments. La frontière n’est donc pas claire pour décider du trouble ou non. La paraphilie est une condition nécessaire mais non suffisante pour devenir un trouble. Les concepteurs affirment que cette approche laisse intacte la distinction entre comportement sexuel normatif et non normatif pouvant intéresser les chercheurs mais ne menant pas automatiquement à considérer un comportement non normatif comme pathologique… Malgré cette nuance, pour officialiser cette position selon laquelle une paraphilie n’est pas en elle-même pathologique, les classes ont été revues : le sadisme sexuel est devenu le trouble sadique sexuel ; il en va de même des autres entités. Du reste, une paraphilie peut être considérée, dans la nouvelle version, comme « pré-pathologique » dans la mesure où les paraphilies se distinguent des « normophilies » ; au plus elles se ressemblent, au plus il faudrait de preuves pour déterminer qu’il s’agit d’une paraphilie. D’après moi, sous réserve de vérification, la « normophilie » est un nouveau néologisme exprimant qu’il est des « manières d’aimer normales » (à moins qu’il s’agisse de ceux qui aiment les normes…) et des « manières d’aimer à côté » (paraphilies) qui peuvent aussi être pathologiques (elles sont alors nommées troubles). Ce néologisme me semble faire l’aveu que les « paraphilies » sont bien du domaine psychiatrique, mordant toujours un peu plus sur le champ de la vie sociale et privée. Par conséquent, être paraphile, c’est ne pas être normal tout en n’étant pas malade… autant dire qu’il s’agit, de mon point de vue, de la définition même de ce qu’est un être humain en tension entre normalité et pathologie. Du reste, le diagnostic de paraphilie fait déjà mettre un pied dans la classification, et il y a fort à parier qu’il ne faudra que quelques efforts pour devenir malade. En fait, on peut facilement prédire que le désarroi du diagnosticien prudent ou, à l’inverse, la certitude de celui qui sait sera plus grand(e) encore qu’il ou elle ne l’était.

En conclusion, il semble bien que les « nouveaux désordres » (Disorders, traduit plus souvent par troubles) du DSM V en trahissent d’autres : épistémologiques, politiques, scientifiques… appelant à ce qu’un nouvel ordre s’établisse par la psychiatrisation et la pénalisation de la vie sociale et privée faisant de certaines de nos « manières d’aimer à côté », certes bizarres mais ni illégales ni pathologiques, de nouveaux objets de médicalisation et de judiciarisation. Ainsi, le juge et le psychiatre seront amenés à coucher dans notre lit ou à l’examiner de près. Il me semble que les dérives de la démocratie devraient pouvoir être considérées comme de nouveaux troubles, possiblement psychiatriques : la passion pour la démocratisation et le consensus devenant suspecte. Ainsi, vais-je plaider pour que le démocratisme fasse partie de la nouvelle version. Il en va de même de la coercition judiciaire ou psychiatrique forçant notre consentement à nous déterminer singulièrement, certes dans des limites qui ne sont jamais claires dès qu’il s’agit de sexualité.

Christophe Adam

BLONDIAUX Isabelle. 2009. Psychiatrie contre psychanalyse ? Débats et scandales autour de la psychothérapie ?, Paris, Le félin.

KIRK Stuart, KUTCHINS Herb. 1998. Aimez-vous le DSM ? Le triomphe de la psychiatrie américaine, Le Plessis-Robison, Synthélabo.

LANE Christophe. 2009. Comment la psychiatrie et l’industrie pharmaceutique ont médicalisé nos émotions, Traduit de l’anglais par François Boisivon, Paris, Flammarion.

LEBRUN Jean Pierre. 2007. La perversion ordinaire, vivre ensemble sans autrui, Paris, Denoël.

2010
03/16
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DSM-V: Getting Closer to Pathologizing Everyone?

For several years, the discussions about the deliberations of the various task forces involved in constructing the latest revision of the Diagnostic and Statistical Manual of the American Psychiatric Association, the DSM-V, have been shrouded in secrecy. The lack of transparency of the discussions generated highly publicized criticisms from such luminaries as Robert Spitzer, the major developer of the revolutionary DSM-III, and Allen Frances, chair of the DSM-IV task force. This situation radically changed in February with the release of the revisions of the changes proposed by the 13 work groups charged with revising the DSM.

Most of the public response to the proposed changes has centered on several alterations to particular diagnostic categories. The suggestions include using a new diagnosis of “temper dysregulation with dysphoria” for children instead of bipolar disorder, incorporating Asperger’s disorder, autistic disorder, and several other conditions into a single “autism spectrum disorders” category, and recognizing some new types of eating disorders. The focus on these specific changes, most of which are sensible, has deflected attention away from other suggestions that have much greater potential import.

Three changes, in particular, could lead to an enormous pathologization of non-disordered conditions. The first is the suggested revision of the criteria for Major Depressive Episode to remove the bereavement exclusion from this diagnosis. At present, the criteria for major depression require five or more out of nine symptoms including sadness or lack of interest or pleasure that least for at least two weeks. However, the criteria exclude people who experience these symptoms in response to bereavement: “The symptoms are not better accounted for by Bereavement” That is, people who develop enough symptoms to meet the criteria after the death of an intimate are nevertheless not defined as disordered but instead as suffering from a natural, nondisordered response to loss.

The reason for the bereavement exclusion is obvious. Voluminous evidence indicates that bereavement after the loss of an intimate is a natural reaction. The earliest literary portrayals of human experience such as Gilgamesh and The Iliad indicate that grief is a basic human emotion. Likewise, while different cultures have vastly different expressions of grief, sadness and accompanying psychological and somatic symptoms after the loss of a loved one is a universal experience. Even many primates show demonstrable signs of depression-like symptoms after the death of a close relation.  In the vast majority of cases, the universal symptoms of grief dissipate with the passage of time and only a minority of the bereaved remains highly symptomatic after several months pass.

If the suggested revision is implemented anyone who is sad, fails to derive pleasure from usual activities, finds it difficult to concentrate, and has sleep and appetite difficulties for a mere two weeks could be diagnosed with Major Depressive Disorder. Because virtually the entire population will be bereaved at some point in their lives and because such a high proportion of the bereaved would meet diagnostic criteria that require two week duration, this proposal could pathologize an enormous number of people.

A second proposal that has the promise of massively medicalizing natural emotions is to adapt dimensional assessments for the existing categorical diagnoses. On the surface, this proposal sounds sensible and desirable. Major Depression, for example, requires the presence of five symptoms but there is no natural cut-off point between four and five symptoms, or at any other particular point for this diagnosis. Depression, as well as the other major conditions in the DSM, seems to naturally be a continuous rather than a categorical condition.

The problem in dimensionalizing common conditions such as depression and anxiety is that a small number of “subthreshold” symptoms typically indicate a non-disordered condition, not a milder form of disorder. The only way to accurately use a dimensional system is to initially use criteria for disorder that separates natural from disordered conditions, regardless of how many symptoms are present. If adequate conceptions of disorder first distinguish contextually appropriate symptoms that are commonly transitory responses to stressors from mental disorders, then dimensional measurement could represent a distinct improvement in the DSM. As the discussion of bereavement indicates, however, the separation of disorders from non-disorders in the DSM-V seems to be getting worse rather than better. The current proposal to dimensionalize measures of frequently occurring disorders threatens to pathologize even mildly distressing conditions. While potentially valuable, it needs reconsideration and reformulation.

A final worrisome proposal lies in the creation of “at-risk” categories for mental disorder. At present, this possible category is limited to psychotic conditions; people who have just one symptom from among delusions, hallucinations, and disorganized speech who have never met the criteria for a psychotic disorder could receive the “at-risk” diagnosis. The diagnosis is well-intentioned and aimed at identifying people who might be at an early stage of a psychotic condition but who don’t yet meet the full criteria. Such people might benefit from early identification and treatment.

The problem with the “at-risk” category is it’s potential as a Trojan horse that would diagnose nearly a-symptomatic people as being in the early stages of a disorder. Yet, at present, there is no way of knowing which people with a single or a small number of symptoms will go on to meet the full diagnostic criteria and which will not. The latter group will typically outnumber the former group so that the potential for false positive diagnoses is enormous.

The current suggested revision only applies to psychotic conditions where it might not create too much damage. If it were applied to widely occurring conditions such as depression and anxiety, however, the result could be a massive amount of new pathology. For example, one of the best known studies of depression, the Dunedin Study, ties the presence of the small allele of the 5-HT gene to this condition. Yet, nearly 20% of people have two copies of the small allele and over half have one copy, so over two-thirds of the population could be viewed as “at-risk” for developing depression . Once a gene is identified as a risk factor for depression, anyone who has the gene may be a candidate for intervention, even if they don’t actually have a depressive condition. Genetic tests could identify “at risk” individuals, who could then be placed on long-term regimes of drug therapies. In the case of the 5-HT gene, a majority of people would be at risk for depression. While the DSM-V working groups have not (yet) proposed an at–risk category for depression or any other commonly occurring condition, this danger might be lurking in the future.

Overall, it appears that the original promise of the DSM-III in 1980 – the creation of a clear, precise, and reliable diagnostic system that would eventually lead to more accurate knowledge about the causes, prognoses, and treatments of mental disorders has not been fulfilled. Indeed, it is difficult to think of a single breakthrough that has resulted from psychiatry’s classificatory system. The major proposals in the DSM-V do not seem as if they will change this situation and could wind up making psychiatry’s central problem of distinguishing pathology from normality even more difficult to resolve.

Allan Horwitz

image©Vincent W. Hevern

2010
03/15
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