This week there has been a large media response to the discussion of DSM-V at the American Psychiatric Association’s (APA) 165th Annual Conference (see also Appendix I). Positive Psychiatry, DSM-V and Mental Health in the older adult population have all been important topics at the APA Conference. There are several videos from the APA Conference on the Webs Health Edge Channel.
Dr James Scully, CEO of the APA gives an overview of the 165th Annual Conference in this video
The President Elect Professor Jeremy Lazarus of the American Medical Association speaks in this video about a trend towards integrated care where Medical and Psychiatric services can work together
An important issue that was addressed at the conference was the criminalisation of people with mental illnesses and this is discussed by Dr Marcia Goin and Dr Ken Rosenberg in this video
In this video, Judge Steven Leifman talks about strategies for keeping people with mental illnesses out of prison
In this video there is a discussion of some of the research that is being presented at the conference
The APA is inviting people including non-APA members to submit comments in response to the draft version of DSM-V in the 6 week period from May 2nd 2012-June 15th. This means that interested individuals or groups can become stakeholders in the revision process. Professor Kupfer has indicated that there have already been more than 11,000 comments submitted from across the world. The APA is inviting people including non-APA members to submit comments in response to the draft version of DSM-V in the 6 week period from May 2nd 2012-June 15th. This means that interested individuals or groups can become stakeholders in the revision process. Professor Kupfer has indicated that there have already been more than 11,000 comments submitted from across the world.
The latest changes in draft version include a clarification on Bereavement Reactions, field trial data supporting the categorical diagnosis of Borderline Personality Disorder, a separation of Language and Speech Disorders, Somatic Symptom Disorder as a combination of two separate disorders and changes to the Neurocognitive and Anxiety Disorders. The more recent changes have also been covered elsewhere in the media.
The New York Times has several feature articles on DSM-V. In this article there is an examination of the Addiction category with the prediction that diagnosis rates will increase with the new criteria. This article looks at the decision to remove Mixed Anxiety and Depressive Disorder as well as the Psychosis Risk Syndrome. There is also a look at the proposed changes in the Autistic Spectrum Disorders and Asperger Syndrome along with recent research findings in this area. Time Magazine covers the proposed change of Post Traumatic Stress Disorder to Post Traumatic Stress Injury in response to the perceived stigma of the word disorder. There is also coverage of the removal of Psychosis Risk Syndrome at Nature. There is also a Reuters piece on some of the changes.
In the Blogosphere there is coverage of the APA Conference at ShrinkRap while in another post, Dinah responds to a critical post about DSM-V by Paula Caplan. There is a good round-up of DSM-V related news at Shrink Things. There is also a round-up which links to more critical views of DSM-V at the AltMentalities Blog which are broadly divided into camps which are either against the concept of a Diagnostic Manual or else are critical of some of the changes advocated in DSM-V.
Appendix I – Other DSM-V Articles on the TAWOP Site
Appendix II – Previous DSM-V Related News Items Discussed on the TAWOP Site
The news items below are unedited and must be interpreted in terms of the subsequent developments. They help to set the context for the current discussion.
DSM-V and ICD-11
The draft DSM-V criterion for a mixed depressive episode are being expanded to fit more closely with clinician’s experience and there are further details here. The new version of the World Health Organisation Classification of Disease (ICD-11) is displayed in draft version here. This is a work in progress with daily updates and it will allow people to comment from July 2011 onwards. I checked out the Mental and Behavioural Disorders section and there was just a little information there (relating to indexes for mortality) at the moment. The World Psychiatric Association have a very interesting paper on the use of the ICD-10 diagnostic system by psychiatrists. The researchers surveyed 4887 psychiatrists across the world using an internet based survey tool. The use of ICD-10 varied from 0% in Kenya and 1% in the USA to 100% in Kyrgyzstan, FYRO Macedonia and Slovenia. 71% of the psychiatrists surveyed used ICD-10 as their main diagnostic system. DSM-IV was the main diagnostic system for 23% of the psychiatrists surveyed (unweighted). 14.1% (unweighted) of the sample set ‘sometimes’ used a diagnostic system and 1.3% used the older versions of ICD-10 – ICD-9 or ICD-8 for diagnostic purposes. There is also a critical look at DSM-V at ‘Boring Old Man’ which highlights the wider debate in society.
The draft changes for DSM-V have been published by the American Psychiatric Association Draft Development Team for DSM-V here. I might have overlooked something but it looks as though it is an overview of the changes being suggested for specific conditions that are being presented.
Firstly I was interested in what amounts to a wholescale reclassification of the Dementias and related conditions into Major and Minor Neurocognitive Disorders. There are some nice ideas contained within this move including the consideration that it is not only memory which needs to be affected. However I was unclear on reading the descriptions of whether it would include the subtypes as I could find no mention of this. However it would be unusual if the various subtypes of dementia for which there is an abundance of evidence were not included as subtypes within this framework as this could be considered a step backward. Additionally I couldn’t find any mention of the term Mild Cognitive Impairment (although there are some broad similarities with minor neurocognitive disorder) and the various subtypes for which there is an emerging evidence base and which is the focus of research in the hope that a better understanding could lead to prevention or amelioration of subsequent dementia.
There were very few changes here. One suggestion was to use a catatonia specified elsewhere instead of catatonia secondary to a medical disorder.
There are some big changes in the Personality Disorders. These have been reduced from 10 to 5. One of the difficulties with the current Personality Disorder types is the diagnostic overlap. A person may fulfill the criteria for more than one type of personality disorder. There are a number of changes to the criteria which should improve reduce the number of comorbid personality disorder diagnoses. A simple Likert-scale is used for quantifying personality and personality traits and the five types are Borderline Personality Disorder, Antisocial/Psychopathic Type, Avoidant Type, Obsessive-Compulsive Type and Schizotypal Type.
There are a large number of new diagnostic labels being considered for inclusion and subsuming current labels. For instance alcohol dependence syndrome may be subsumed under Alcohol-use disorder. Cannabis withdrawal is another diagnosis being introduced. The discussions around the terms ‘addiction’ and ‘dependence’ are discussed below.
There are big changes to the diagnosis of Schizophrenia with a proposal for removing subtypes including Paranoid Schizophrenia, Disorganised and Catatonic schizophrenia. Changes are being suggested in order to bring DSM-V into closer alignment with ICD-10. Proposed changes to the criteria for Schizoaffective Disorder are meant to increase reliability. ‘Psychosis Risk Syndrome‘ is being introduced (see further discussion below) and a Catatonia Specifier is being suggested. This is apparently because catatonia is ‘often not recognised’.
Mixed anxiety and depression disorder is being introduced with criteria that avoid ambiguity. This is currently included in the appendix of DSM-IV. There is a proposal to rename Dysthymic Disorder as chronic depressive disorder. There is a proposal to replace Bipolar Disorder Most Recent Episode Mixed with a mixed specifier. There are a number of changes in the criteria of Manic Episode particularly around energy levels.
The proposal is to include Obsessive-Compulsive Disorder under a new category of ‘Anxiety and Obsessive-Compulsive Spectrum Disorders’. The changes here are further discussed in the ‘PsychBrownBag’ Blog and the ‘OCD Center of Los Angeles’ Blog below.
There is a proposed amalgamation of four conditions into ‘Complex Somatic Symptom Disorder‘ but for further discussion see the ‘OCD Center of Los Angeles’ Blog below.
The proposal is to reclassify Factitious Disorders under Somatic Symptom Disorders.
Theere is a proposal to subsume Dissociative Fugue under Disssociative Amnesia. Similarly there is a proposal to remove Dissociative Trance Disorder and integrate the criteria into the diagnosis of Dissociative Identity Disorder which has a number of other proposed changes.
There are a number of new diagnoses.
A new diagnosis of Binge-Eating Disorder is recommended (for further discussion see below). In Anorexia Nervosa there is the proposal to remove the criterion of amenorrhoea whilst in Bulimia Nervosa there are some proposed changes to the frequency of binge eating episodes and the purging criteria.
There are a number of new conditiosns (a number of which subsume other conditions) including Klein-Levin Syndrome, Primary Central Sleep Apnoea, Primary Alveolar Hypoventilation, Rapid Eye Movement Behaviour Disorder and Restless Leg Syndrome amongst others. There are a number of changes to the criteria for narcolepsy including hypocretin deficiency.
There are a large number of suggested changes including the removal of Rett’s Disorder, a number of proposed changes to the Attention Deficit and Hyperactivity Disorder criteria, the inclusion of Post-Traumatic Stress Disorder in school age children and Temper Dysregulation Disorder with Dysphoria which is further discussed below. Interestingly the wording for Separation-Anxiety Disorder may be changed so that it can be used with adults also. This is because there is evidence for an adult separation-anxiety disorder.
There is a proposal to move Adjustment Disorder to a grouping of Trauma and Stress-Related Conditions.
Discussion of the Draft DSM-V Changes Elsewhere in the Media
Links to some of the discussions elsewhere in the media are given below.
The Time article looks at a number of proposed changes for DSM-V which includes the criteria for making a diagnosis of depression,use of a continuum and the case for autistic spectrum disorders, the possible grouping of non-dependence inducing substances together with dependence inducing substances in the addiction and related disorders, reducing the number of personality disorder types and making some amendments to some of the sexual disorders. Over at PsychCentral, Dr Grohol looks at a number of features of the DSM-V draft. He is encouraging of the inclusion of Binge Eating Disorder, but is critical of the criteria used in Minor Neurocognitive Disorder, Behavioural Addictions and also Temper Dysregulation Disorder which has a narrow time period fo 6 to 10 years for diagnosis. Over at the ‘Psyche Brown Bag‘ blog, Joyce Anestis comments on the restructuring of the multiaxial system as well as the arrival of a number of new disorders including ‘hoarding disorder’, ‘olfactory reference syndrome’, ‘skin picking disorder’ and ‘psychosis risk syndrome’ amongst others and is also confused by the proposed changes to the personality disorders. The Times has a look at a number of the proposed changes including ‘sluggish cognitive tempo disorder’. Web MD has an article on the changes and features an interview with Dr First who is critical of the utility of the diagnosis of ‘Psychotic Risk Syndrome’.
Dr Dan Carlat has a discussion of the proposed criteria on his blog and seems fairly positive on these (however I would just add that there are neurobiological criteria for a number of disorders in DSM-IV/DSM-V draft e.g Hypocretin Deficiency in Narcolepsy above). He notes that Temper Dysregulation Disorder is being favoured as it would avoid a diagnosis of Bipolar Disorder in children in a number of cases. He’s in favour the use of addiction in place of dependence or abuse and also the use of the concept of Binge-Eating Disorder. The New York Times has a piece featuring interviews with several psychiatrists and 230 comments at the time of writing. Integral Options cafe has links to a number of posts including those on the NPR site. An article at the NPR website examines the limits of the checklist approach and how severity might be measured when using a dimensional approach. The Economist has a piece on the history of the diagnostic criteria but also cover some of the disputes that have taken place. ‘DSM-V and ICD-11 watch’ have some interesting links as well as a brief look at suggestions for medically unexplained symptoms. Dr Finnerty has an overview of proposed changes as well as some useful links. Mind Hacks has coverage here and here. The APA have a facebook site that interested readers can join.
Stanton Peele covers the proposed use of the term addictions in this ‘The Huffington Post’ article. The ‘Join Together‘ website features an interview with Dr Charles O’Brien who is chair of the APA’s DSM substances related disorders workgroup. He explains the distinction between dependence and addiction and the consideration of including the term addiction in DSM-V. They also discuss the possibility of collecting behavioural addictions together with alcohol and other drug related disorders.
Anxiety Disorders and OCD
Tom Corboy director of the ‘OCD Center of Los Angeles’ writes about a number of proposed changes over at the ‘OCD Center of Los Angeles’ blog. Thus Corboy discusses the suggested use of an ‘Anxiety and Obsessive Compulsive Disorder Spectrum’. Corboy is also critical of the suggestion of agaraphobia without panic disorder, in favour of moving Body Dysmorphic Disorder into the ‘Anxiety and Obsessive Compulsive Disorder Spectrum’ and adding a muscle dysmorphia variant, critical of the aggregation of 4 somatoform disorders including hypochondriasis, in favour of the relabelling of trichotillomania as ‘hair pulling disorder’ and also for the inclusion of skin picking disorder.
Over at the blog ‘Mental Incompetence and the Death Penalty‘ there is a guest post by Dr Watson. He criticises the proposed criteria for intellectual disability on the basis that there doesnt appear to be a consideration of the standard error for IQ testing meaning that there is what he describes as a ‘bright light’ cut-off point of 70 or below whereas in practice there is a group that are scored over 70 who would still be included amongst a number of criticisms.
Bipolar Disorder in Children
Over at the NPR website, there is a wider discussion of the diagnosis of Bipolar Disorder in children as well as the more recent ‘Temper Dysregulation Disorder’.
Autistic Spectrum Disorders
The Left-Brain Right-Brain blog compares the criteria in DSM-IV with those in DSM-V for autistic disorder and autistic spectrum disorders respectively and links to a number of other articles on the subject. There is another discussion of the autistic spectrum disorders proposition here. There is further coverage here and here.
Dr Dan Carlat takes a further look at the DSM-V draft proposals here. Dr Charles Parker has further coverage here and also over at the Corpus Callosum blog. There is a look at grief in the draft DSM-V proposals at Psychotherapy Brown Bag.
DSM-V and ICD-11
In the BJPsych there is an interesting article by Professor Michael First who writes about the potential for harmonisation of DSM-V and ICD-11 which is a widely discussed topic (First, 2009). There are a number of points of interest in the article and he notes that there are investigators involved with revisions of both systems which should help to contribute to attempts to harmonise both systems. The discussions around these systems will no doubt increase.
There was discussion recently of the diagnosis of Asperger syndrome being dropped from the next edition of the DSM and this will mean an expansion of the autism diagnostic category. This was originally discussed in a New York Times article (which requires (free) registration). The article features an interview with Dr Catherine Lord, who is one of 13 members of the working group on autism and Neurodevelopmental Disorders. The group are considering a number of amendments to the autism diagnosis including the addition of comorbidity that have been associated with the condition including disorders of attention and anxiety. However the suggestion regarding Asperger syndrome has not yet been ratified by the group. There have been a number of responses in the media. This article contains interviews with a doctor who runs a clinic, a parent of a child with Asperger’s syndrome and the president of a non-profit organisation for raising awareness of the condition. There is some information on the DSM-V process here.
DSM-V is due to appear in 2012. A twitter campaign has been started to petition for the inclusion of Depressive Personality Disorder in DSM-V. Professor Simon Baron-Cohen has argued against the removal of the Asperger Syndrome label in this New York Times article. Dr Anestis offers his views on this article and Baron-Cohen responds in this blog post.
Michael First. Harmonisation of ICD-11 and DSM-V: Opportunities and challenges. The British Journal of Psychiatry. 2009. 195. 382-390.
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