Thursday, February 18, 2010

DSM – “V” – For Vendetta

“There is more behind and inside of V than any of us had suspected.”

- “V For Vendetta”

It has been over a decade, and “V” has finally revealed itself. In the mental health community, the quarrels and contretemps are escalating. This time, my obscure reference may be too inscrutable, but I am begging your indulgence, as it was too tempting to pass up the opportunity to reference a good movie/novel/piece of English history. The novel “V for Vendetta” was made into a movie, and was loosely based on an actual historical event, now celebrated in England every November 5th as “Bonfire Night.”

It turns out that a gentleman by the name of Guy Fawkes was part of an anarchist plot to overthrow England’s aristocratic, Protestant rule. The plan involved using kegs of gunpowder to blow the Houses of Parliament – with the King and nobility inside. Fawkes and other English Catholics felt targeted by a systematic discrimination, carried out by King James I and the Protestant nobility. Although the explosive “gunpowder plot” was thwarted by an anonymous letter with only hours to spare, “Guy Fawkes Night” is still celebrated on November 5th with fireworks displays in parts of the UK. And so just as the Gunpowder Plot was planned and prepared for in secrecy (until the last few hours), so too have the efforts of the DSM-V work group been accused of carrying out most of their “mission” shrouded in secrecy..... until now, and with only a few months to spare.

Only very recently, in early February of 2010, the “DSM-5 Work Group” has posted on the web the “preliminary draft revisions” at: The posting is now “available for public review and comment,” and “viewers will be able to submit comments until April 20, 2010.” So no rush or worry (?!). The greatly anticipated publication of the 5th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5), promised for “May 2013,” will mark one the most anticipated events in the mental health field. But prior to this date, we have all been given a (very) brief window to review the proposed work product, and are informed that what is currently on the website is “not final,” but “initial drafts of the recommendations that have been made to date by the DSM-5 Work Groups.”

A quick perusal over the DSM-V site quickly impresses upon one that this would appear to be a DSM like no other before it. The suggested revisions are extensive, and the changes striking. Finally, the expectations that harried clinicians perform so-called “dimensional assessments” and scoring “cross-cutting” symptoms during all diagnostic evaluations make for a curious combination, particularly as to how all this will generalize to everyday practice “in the trenches.” The odd, even erratic manner in which this iteration of the DSM has come about has drawn significant attacks from various quarters of the mental health field, as well as other interested parties. This article will provide a brief introduction and summary to DSM-V, as well as some of the major criticisms to date.

Intro to DSM

I assume some familiarity (even expertise) in a substantial portion of the CMHR readership, but by way of quick review: DSM stands for Diagnostic and Statistical Manual of Mental Disorders. It is published by the American Psychiatric Association (APA), and contains descriptions, symptoms, and other criteria for diagnosing mental disorders. This is important in that it provides mental health professionals criteria and diagnoses for a common language that can be used to treat patients.

Thus, one goal of the DSM is to help ensure accuracy and consistency of diagnosis. The site aptly points out that “Only by having consistent (reliable) diagnoses can researchers compare different treatments for similar patients, determine the risk factors and causes for specific disorders, and determine their incidence and prevalence rates.” Over the past 60 or so years, the DSM has been periodically reviewed and revised since the publication of DSM-I in 1952. Thus, the manual requires periodic updates to reflect any new discoveries and/or advancements.

Major Revisions

The progression from DSM-IV to DSM-IV-TR (Text Revision) was more or less atraumatic. The revisions were quite minor, and did not substantially affect clinical practice. In contrast, it appears that the changes from DSM-IV-TR to DSM-V would be dramatic – that is, if all goes as planned by the DSM-V work group. How dramatic? I’ll give a few examples, but remember that interested persons may go on the web and form their own opinions. Some of the “draft revisions” listed on the site include (in no particular order):

♣ A single diagnostic category, “autism spectrum disorders” incorporating autistic disorder, asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder.
♣ Eliminating substance abuse and dependence, and replacing them with “addiction and related disorders.”
♣ Creating a new category, “behavioral addictions,” in which gambling will be the sole disorder. [JK: Sole disorder? Already I’m confused].
♣ A proposed new diagnostic category, temper dysregulation with dysphoria (TDD). The dsm5 site explains that TDD’s “new criteria are based on a decade of research on severe mood dysregulation, and may help clinicians better differentiate children with these symptoms from those with bipolar disorder or oppositional defiant disorder.” [JK: Distinguish from oppositional defiant disorder (ODD)? The first criterion for ODD is: “1) Often loses temper….”].
♣ Major revisions to the description and criteria for personality disorders (see below).
♣ Discontinuing the use of all subtypes of Schizophrenia. [JK: This one simply boggles the mind. The dsm5 website explains that “A powerful argument for discontinuation of the use of subtypes in schizophrenia is that administrative psychiatric practice data collected in the US and Europe show that most are rarely used diagnostically (<5%), with the exception of paranoid schizophrenia (50-75%) and, to a lesser extent, undifferentiated schizophrenia. It could be argued, however, that subtypes may show genuine epidemiological variation and therefore should be retained. The larger question, therefore, is whether there is evidence that subtypes are valid.” In my opinion, this statement is highly revealing. Administrative data?? Are we doing psychiatric science here, or have we completely handed over the field to the “business” of medicine?]

I could continue, but my physician advised me it would exacerbate my TDD. So, the final draft of DSM-V will be submitted to the APA’s Assembly and Board of Trustees for review and approval. The final product is “predicted” to be released in May 2013, but many in the field are not optimistic about this deadline. At this point, you may be wondering: “What process did they use to guide their revisions?” Well, the site has a ready answer for you – the process was guided by “four principles”:

1. The highest priority is clinical utility – that is, making sure the manual is useful to those who diagnose and treat patients with mental illness, and to the patients being treated. [JK: More on the subject of “clinical utility to come..].
2. All recommendations should be guided by research evidence.
3. Whenever possible, DSM-5 should maintain continuity with previous editions
4. No a priori restraints should be placed on the level of change permitted between DSM-IV and DSM-5 [JK: Maintain continuity…. no restrictions on changes? Where is the nearest TDD clinic?]

Points 3 and 4 remind me of the classic Star Trek episode where Captain Kirk defeats a robot by forcing it to consider two contradictory pieces of logic in its programming. The robot begins to sputter nonsense, followed by sparks, smoke and an explosion. Only here – we are that robot. But dsm5 assures us that this absolute contradiction in logic is not what it appears to be, as the site has an explanation for this: “The third and fourth principles may seem contradictory, but both principles are necessary…” [JK: Well now it’s obvious. They are trying to increase the prevalence of TDD…].

And speaking of temper dysregulation, I promised a word about the changes being considered in the controversial arena of personality disorders. In fact, the DSM-V work group has recommended a revised definition of the basic term/construct “personality disorder,” as well as a corresponding revised set of criteria. The new definition of a personality disorder would be a “failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual’s cultural norms and expectations.” Clear enough? If not, the basic components are further broken down in excruciating detail and defined. Terms such as: adaptive failure, identity integration, integrity of self-concept, and self-directedness, are all handily, albeit hazily defined.

My colleague, Dr. Robert Gregory, a national leader in the study, evaluation and treatment of Borderline Personality Disorder has precisely pointed out to me that personality disorders work group is “proposing a radical redefinition of what constitutes a personality disorder.” But this radical redefining, particularly for Borderline Personality Disorder, uses terms that are closer to common psychoanalytic concepts, as opposed to the DSM-IV-TR approach of leaning more towards simple behavioral descriptors. Now for proponents of psychoanalytic theory (among which I count myself), this would not appear to be a bad thing. However, Dr. Gregory correctly notes that few have the training and/or expertise to apply the relevant psychoanalytic concepts in an effective, meaningful way.

Antisocial or Psychopathic?

Correctional and forensic professionals may be eager to learn more about an old, familiar friend – Antisocial Personality Disorder (ASPD). In contrast to Borderline Personality Disorder, the re-formulation of ASPD does not rely on such psychoanalytically based descriptors. Nor does it resemble the more cut and dry, behavioral descriptors of ASPD found in DSM-IV-TR (long criticized for potentially “capturing” mainly low socio-economic status, underprivileged, minority and “caught/convicted” criminals). So, does DSM-V clarify this personality disorder and give a definition with “clinical utility”? Surprisingly, the work group is recommending that ASPD “be reformulated as the Antisocial/Psychopathic Type.” Now I will admit to possibly missing something here, but I will ultimately plead confusion. It was my understanding that future DSMs were contemplating adding Dr. Hare’s construct of Psychopathy – as it is not synonymous with ASPD, as every correctional mental health professional knows by now.

To my great astonishment, DSM-V appears to want to “blend” these two constructs together – which seems to me to present so many problems, an entire text might written about them. Because of the special interest of this diagnosis to correctional mental health, I will give the proposed revision in some detail. The “reformulated” diagnosis of Personality Disorder, “Antisocial/Psychopathic Type” would be as follows (I underline portions that seem to me especially problematic and open to misunderstanding and/or abuse):

Individuals who match this personality disorder type are arrogant and self-centered, and feel privileged and entitled. They have a grandiose, exaggerated sense of self-importance and they are primarily motivated by self-serving goals. They seek power over others and will manipulate, exploit, deceive, con, or otherwise take advantage of others, in order to inflict harm or to achieve their goals. They are callous and have little empathy for others’ needs or feelings unless they coincide with their own. They show disregard for the rights, property, or safety of others and experience little or no remorse or guilt if they cause any harm or injury to others. They may act aggressively or sadistically toward others in pursuit of their personal agendas and appear to derive pleasure or satisfaction from humiliating, demeaning dominating, or hurting others. They also have the capacity for superficial charm and ingratiation when it suits their purposes. They profess and demonstrate minimal investment in conventional moral principles and they tend to disavow responsibility for their actions and to blame others for their own failures and shortcomings.

Individuals with this personality type are temperamentally aggressive and have a high threshold for pleasurable excitement. They engage in reckless sensation-seeking behaviors, tend to act impulsively without fear or regard for consequences, and feel immune or invulnerable to adverse outcomes of their actions. Their emotional expression is mostly limited to irritability, anger, and hostility; acknowledgement and articulation of other emotions, such as love or anxiety, are rare. They have little insight into their motivations and are unable to consider alternative interpretations of their experiences.

Individuals with this disorder often engage in unlawful and criminal behavior and may abuse alcohol and drugs. Extremely pathological types may also commit acts of physical violence in order to intimidate, dominate, and control others. They may be generally unreliable or irresponsible about work obligations or financial commitments and often have problems with authority figures.

So in summary, this “narrative” description is a confusing amalgam of the DSM-IV diagnosis of not only ASPD and psychopathy, but also Narcissistic Personality. Here, I would like to make a few comments on the sections I underlined, as I believe them to be particularly problematic. Recent (and not so recent) research has clearly suggested that there is not “one” type of psychopath. There may be impulsive/aggressive types, which are distinct from conning, glib, manipulative types. This has been well researched for many years, and it is surprising that it is not reflected in the DSM-V proposed drafts., Instead, we are presented with a hodgepodge of problematic narrative which blends the constructs of ASPD, Psychopathy (both impulsive/aggressive and conning/manipulative types) and Narcissistic Personality Disorder in a confusing manner.

The section on impulsivity/aggression and sensation seeking is simply not observed in all persons with either ASPD or Psychopathy. For those interested, please see the developing literature on “successful” psychopaths, as well as “white collar” psychopaths. In fact, allow me to provide you with the words of the foremost expert in the field, Dr. Hare (developer of the Psychopathy Checklist):

Unfortunately, there is no scientific evidence concerning the number of psychopaths in business….few organizations will provide the sort of access to their staff and files required to do proper assessments….Second, psychopaths have a talent for hiding their true selves, so one could expect many to go unnoticed and uncounted, leading to an underreporting of psychopathy…. Third, psychopathic-like traits and behaviors are also exhibited by some individuals who are not truly psychopathic, which could lead to overreporting…(p. 177)10

Thus it seems unnecessarily confusing to combine two distinct clinical constructs (albeit with some overlap – the majority of persons with ASPD will not be psychopaths, but the majority of psychopaths will meet DSM-IV-TR ASPD criteria) that have long been researched as separate entities. In addition, I need not cite any specific literature to inform you that the label of “psychopath” can have a powerfully damning affect. I would go so far as to say that it has unfortunately become almost synonymous with calling someone “evil.” Are we seeking to paint all persons with ASPD with this ultra-toxic brush stroke? I have some serious, realistic concerns here. No longer will some 50 to 60% of all convicted prison inmates be diagnosed with “Antisocial Personality Disorder” – now they will be “Antisocial/Psychopathic” Types. I contend that this new label is not only confusing, but it is also not in line with the current social science, and likely to produce unnecessary stigma.

Next, the issue of “remorse” has long deserved attention that is more than a mere “gut” reaction and subjective conclusion on the part of the evaluator. The Latin root of remorse – mordere, means “to bite,” as in to feel the bite of one’s own guilt and moral anguish. The importance of remorse in society is that is that when an individual has broken a societal law, the criminal justice system (and society) expects that “they show some contrition,” and thus it “follows that offenders who are remorseful should not be treated more leniently.” Consider too that the concept of “lack of remorse” is a specifically named criterion in the diagnoses of both ASPD and Psychopathy.

Now stop and ask yourself this – do we have scientifically reliable methods of detecting and/or measuring genuine remorse? I realize that the same criticism could be leveled at many other diagnostic criteria. For example, in Major Depression, we have the presence of “depressed mood,” or “inappropriate guilt.” However, it is “remorse” that stands alone as a powerfully influencing impression, with consequences that may involve liberty and even death. In the law, when something is assumed to be true, even though it may be untrue, it is called a “legal fiction.” It has been noted that “Legal fiction is the mask that progress must wear to pass the faithful but blear-eyed watchers of our ancient legal treasures. But though legal fictions are useful in thus mitigating or absorbing the shock of innovation, they work havoc in the form of intellectual confusion.” Similarly, I contend that our current construct of remorse is often both a legal and psychiatric fiction.

In both the law and psychiatry, the determination of the presence of remorse is, more often than not, some combination of intuition, bias and projection. Unless the subject, after the proscribed act, states with conviction: “Yes. I did it, and I don’t feel a bit sorry for it,” remorse can only be indirectly inferred, perhaps from behavioral evidence. But even this is sometimes tricky. I will save for another time the manifold problems surrounding the ease with which remorse may be simulated, or alternatively, be genuinely present yet not expressed in a way that is perceptible (or perhaps acceptable?) to outside observers. I would only leave the reader with my own “cautionary statement” from my forensic travels. If I were to collect a dollar for every instance in which I read a jail mental health progress note describing a seriously mentally ill defendant (still sick and on heavy doses of antipsychotics) as showing “no remorse for his crime,” I would be in a position to develop and publish my own manual of mental disorders. [JK: In fact, my father has already accomplished this on a highly restricted budget, using a community mental health center’s spare office supplies. He has dubbed it the “DSM-K”].

Finally, I must comment on the phrase “acknowledgement and articulation of other emotions, such as love or anxiety, are rare.” This is problematic for several reasons. I will address the easy reason first – as anyone who has worked with antisocial or psychopathic offenders can attest to, many are capable of, and even excel at, “articulating” said emotions. Of course, they may not at all mean what they say, but they are most certainly capable of convincingly articulating, mimicking or pantomiming emotions. I have no doubt that Bernie Madoff was able to generate an “aura” of caring and trust for the victims of his staggering Ponzi scheme. So the phrase “acknowledgment and articulation” seems misleading at best. I could go on about how I’ve encountered inmates who met ASPD criteria and still had the capacity for “love or anxiety,” but I’d put myself at risk of being drummed out of the profession.

Recall the important “principle” that DSM-V diagnoses have “clinical utility” for those hard working clinicians? If one was to consider making the diagnosis of ASPD, and one had circumnavigated the above mentioned confusion, a final task still awaits. The clinician would still need to: 1) rate the patient for how well he/she “matched” the narrative description, and 2) then rate the extent to which certain traits are descriptive of the patient. These ratings take the form of Likert-type scales. For example:

A. Type rating. Rate the patient’s personality using the 5-point rating scale shown below. Circle the number that best describes the patient’s personality.

5 = Very Good Match: patient exemplifies this type
4 = Good Match: patient significantly resembles this type
3 = Moderate Match: patient has prominent features of this type
2 = Slight Match: patient has minor features of this type
1 = No Match: description does not apply

My thoughts here concern the issue of inter-rater reliability, and how one examiner’s rating of “3” can easily be another’s rating of “5.” Perhaps another time, I will delve into the other constructs that DSM-V is proposing that clinicians assess – such as “dimensional assessments,” and “cross-cutting assessments.” But for now, let me just note that they involve more “scale” ratings of various types of symptoms. The site assures us that these assessments will be “brief,” “simple,” and “useful.” After reviewing the website and the instructions, I am less optimistic. Indeed, I have a genuine concern that adding these extra ratings/assessments to all the paperwork and “chart treating” clinicians already have to contend with will be the breaking point. At best, clinicians may comply, but do so in a half-hearted, slap-dash way. In short, busy clinicians struggling to keep pace in the clinics will simply find all this to be too much.

Serious Criticisms

It’s not just me. The field is currently rumbling with DSM-V criticisms, and I wanted to give the readers some examples of what other mental health professionals are saying. Dr. Frances, former chair of the DSM-IV Task Force and currently professor emeritus at Duke, has given litany of concerns that are worth considering, including:

♣ Poor and inconsistent writing
♣ Problematic “new” diagnoses
♣ Lowered thresholds for mental disorders
♣ Questionable expanding of boundaries of the disorders
♣ Creating higher rates of mental disorder

Dr. Frances’ critique concludes that “DSM5 has been and remains in serious trouble…. What leads us to this pessimistic conclusion? Every step in the development of DSM5 has been secretive and disorganized. The leadership has established a consistent track record of proposing unrealistic plans and impossible to meet timetables―with predictably erratic course changes and repeatedly missed deadlines.” And as regards my concerns about utility for the hard working clinician, this point is again stressed in a more eloquent manner:

It is inherently difficult for experts, with their highly selected research and clinical experiences, to fully appreciate just how poorly their research findings may generalize to everyday practice―especially as it is conducted by harried primary care clinicians in an environment heavily influenced by drug company marketing. They also consistently underestimate the costs and risks of medication treatment when it is given to those who don't really need it…. the DSM5 suggestions display the peculiarly dangerous combination of nonspecific and inaccurate diagnosis

Dr. Frances concludes that now the “responsibility (and opportunity) for rescuing DSM5 falls most heavily on the field at large and on the Oversight Committee. Now that the DSM5 drafts are finally open for wide review, it behooves the field to be active in identifying problems and providing the needed pressure to ensure they will be corrected.” Agreed, but can this be done effectively in short time allotted?

But why am I making such a fuss over all this? Haven’t we been here many times before from DSM-I to DSM-IV-TR? Perhaps, but there are now different forces at play in 2010. As one eminent psychiatrist, Dr. Michael First, told the NY Times: “Anything you put in that book, any little change you make, has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who’s considered to be normal or not, for who’s considered disabled.”

Does It Help Reduce Suffering?

In my own opinion, the fluctuating boundaries of mental disorders will continue to be debated until we devote sufficient time and attention to developing improved, scientifically valid and reliable methods of testing and effectively treating mental disease. Another highly respected colleague, Dr. Ron Pies, has pointed out to me that treatment efficacy in psychiatry is often grossly underappreciated. Psychiatry’s treatment success rates for certain disorders are sometimes higher than other areas of medicine. For example, psychiatry’s treatment success rate for Panic Disorder, Obsessive Compulsive Disorder and Bipolar Disorder are significantly higher than the treatment success rates of angioplasty or arthrectomy. Ultimately, in psychiatry, what we need are diagnoses that are: 1) practical, and 2) help us “target” an illness, so that we can reduce “suffering and incapacity” in patients. In other words, if the “diagnostic system” does not help us reduce a patient’s suffering and incapacity, of what use is it?20

By the looks of DSM-V thus far, we appear to be at some risk of distancing ourselves from these goals. So what do we have to work with now that we can count on? I would assert that it is the lost art of the masters – the art and skill of the clinical interview. From Kraepelin to Freud to Cleckley – it was their rich clinical descriptions that helped us navigate the foreign terrain. But note well that they came across their insights by spending much time listening, observing and questioning patients – a practice that has been subordinated to ten minute med checks, diagnostic coding and billing. It has been observed that:

All too many training programs in psychiatry are neglecting psychodynamically informed interviewing and clinical reasoning skills. Recently, the American Board of Psychiatry and Neurology eliminated oral interviewing as a requirement for board certification. The rationale has been given that oral interviewing will be evaluated during residency, when problems can be remedied, rather than belatedly at the completion of training. That this rationale would not apply to other skills being taught is curious.

Perhaps the “vendettas” surrounding DSM – “V” are just what we needed to awaken? Our own version of “Guy Fawkes Day.” It is no accomplishment that the highest court in the land, the US Supreme Court, is clearly skeptical of the reliability of psychiatric diagnoses and evidence of mental disorders. , By the looks of it, DSM-V will need far more oversight, feedback and re-working. Thus, I am advocating for a considerable extension of the DSM-V timeline. Instead of the proposed release date of May 2013, I would suggest a new release date: November 5, 2015, in honor of the famous November 5, 1605 Guy Fawkes Day. And on that day, let all the scientifically unsound walls of “psychiatric parliament” fall away.

Remember, remember
The fifth of November!

References (provided on request)