Psychiatry’s Bible Revised

We cut nature up, organize it into concepts, and ascribe significances as we do, largely because we are parties to an agreement to organize it in this way—an agreement that holds throughout our speech community and is codified in the patterns of our language." - Benjamin Lee Whorf

Most people don’t know what the Diagnostic and Statistical Manual of Mental Disorders (DSM) is. The first time I heard of it was in a Chuck Palahniuk’s novel several years ago (I think it was ‘Survivor’, but I don’t remember really).

The DSM is without any doubt, the most important book in psychiatrists’ clinical practice. It’s a reference guide full of lists of symptoms that define mental disorders. The DSM determines the type of diagnoses clinicians make. Psychiatrists move inside the boundaries defined by the DSM.

The book has undergone several revision, the current version is the DSM-IV-TR, published in 2000 that contains little updates compared with the previous version, the DSM-IV, published in 1994. So the upcoming version, the DSM-5, will be the first substantial change to psychiatric diagnosis in more than 20 years, (and some say more than 30).

The new version will probably be published in May 2013, and in 2010 the American Psychiatric Association posted a draft on their Web site open for comments. A good thing, if you ask me, that has allowed a large number (500000) of people to read and comment on such an important book.

The APA received several criticism about the new criteria and diagnoses. I will try to sum up some of them. 

But first I need to adress a simple yet important fact: there are no biological tests for mental disorders. Maybe there will be, one day, but for now psychiatry has a diagnostic system without objective tests.

Psychiatric diagnoses are descriptive diagnoses based on lists of symptoms on which there is a certain degree of agreement. Nevertheless some research showed that these criteria are not always reliable.

Different disorders have many common symptoms making difficult to distinguish what diagnosis best applies, and it is suggested that the same disorder can display different symptoms in different cultures or environments.

The new version of the DSM tries, at least in part, to adress this problem, eliminating some less distinct diagnoses or merging them under more comprehensive categories. This is one of the reasons the DSM-5 will no more contain a distinct diagnosis for Asperger’s syndrome, Autistic disorder, childhood disintegrative disorder (CCD) or pervasive developmental disorder not otherwise specified (PDD-NOS), thought to be too similar to each other. There will be instead the diagnosis for Autism Spectrum Disorder that will encompass all these disorder in one larger categories.

The attempt to achieve more accurate diagnoses has led the DSM-5 Task Force to implement in the new version a rating system to grade the severity of the patients’ symptoms. Doubts have been cast: how will insurance companies respond? Will they demand that the patient’s symptoms meet a certain severity to agree in order to cover for the treatment? Will psychiatrists use this system in their clinical practice given that it will probably require more tests, evaluations, paperwork and time?

If you would like to make it short, there are two kinds of critics:

Some psychiatrists contend that the volume still contains more disorders than actually exist, encouraging superfluous diagnoses—particularly in children. Others worry that the stricter, more precise diagnostic criteria may inadvertently give insurance companies new ways to deny medication to patients who need it. - Psychiatry’s “Bible” Gets an Overhaul

I personally think that, without losing sight of the second kind of critics (because it’s very important), we should acknowledge that it’s more a matter of public policy and less a matter of scientific validity.
The APA conducted some “field trials” to test the reliability of the new diagnoses. The results has not yet been published but the APA gave a preview during its annual meeting in Philadelphia. 
The APA uses a statistic called kappa to measure the reliability of different diagnoses. The higher the value of kappa, the more reliable the diagnosis, with 1.0 representing perfect reliability. The APA considers a diagnosis with a kappa of 0.8 or higher miraculously reliable; 0.6 to 0.8 is excellent; 0.4 to 0.6 is good; 0.2 to 0.4 “could be accepted” and anything below 0.2 is unacceptably unreliable. - Field Tests for Revised Psychiatric Guide Reveal Reliability Problems for 2 Major Diagnoses
The kappas of many diagnoses look strong, for example the new Autism Spectrum Disorder has a kappa of 0.69.
But for Generalized Anxiety Disorder and Major Depressive Disorder things don’t look that good. The kappa for Generalized Anxiety Disorder is about 0.2 and that for Major Depressive Disorder is 0.3. These are worrying results, seen that these are two of the most common disorders. 

Some ask (doubting) if the American Psychiatric Association is best equipped to develop and monitor such an important diagnostic system, one that can profoundly influence the lives of many people, alone. Criticisms have pointed out that the APA has refused to subject the new criteria to a more large and independent scientific review.

At least one previous research (Cosgrove, Krimsky, Vijayaraghavan & Schneider, 2006) has showed how the majority (56%) of the psychiatrists who contributed to the diagnostic criteria produced for the DSM-IV and the DSM-IV-TR had one or more financial associations with companies in the pharmaceutical industry. Pharmaceutical companies are not so likeable, so some people see conspiracy in these matter. But others say that:

This is not true. The mistakes are rather the result of an intellectual conflict of interest; experts always overvalue their pet area and want to expand its purview, until the point that everyday problems come to be mislabeled as mental disorders. Arrogance, secretiveness, passive governance and administrative disorganization have also played a role. - Break Up the Psychiatric Monopoly

Anyway there are several reasons for concern. One of this is the proposal to eliminate the “bereavement exclusion”a criteria now in use in the DSM-IV for the diagnosis of Major Depression which recognizes that depressive symptoms are sometimes normal in recently bereaved individuals. This is not just a failure in recognizing the difference between a proportionate response to a devastating emotional event and a mental illness that carry the risk to make a caricature of psychiatry, but also a problem that could lead to overdiagnosis and overmedication. 

From the online release of the draft version of the DSM-5, a enormous quantity of articles have criticized the new diagnostic system, and even if sometimes these criticisms misread or simplify too much the problems, it is clear that something is wrong.

The DSM taxonomy, representing putative categories that demarcate boundaries between normality and abnormality, seems to be wide-ranging, making efforts to describe many supposed human aberrations.

Psychiatric labels can influence perception powerfully. Categorization or labeling can assist in understanding and organizing phenomena in our complex social world, convey information in a simplified manner, and aid in making predictions. Additionally, psychiatric labels may assist in understanding the cause of behavior, facilitate communication among professionals, and provide a framework through which behavior can be described, explained, and treated.
However, to the extent that psychiatric labels facilitate understanding of behavior, they also have the potential to bias judgment. 

Iatrogenic symptoms in psychotherapy. A theoretical exploration of the potential impact of labels, language, and belief system (2002) by Boisvert and Faust.

Psychiatric labels can lead to erroneous interpretations about patients experiences as resulting from his/her disorder; too readily personality attributions about the cause of the problems; overattributing greater maladjustment than what actually is; tendency to focus on the client rather than on the situation thinking that the problems reside inside the person, etc. Psychiatric labels can also “contribute to negative self-perceptions and stereotyping, jeopardize social acceptance, and generate negative attitudes in the public" (ibidem).

Even without considering all these possible negative consequences of the DSM taxonomy, it should be acknowledged that the DSM has a large impact in many ways, including shaping ideas and expectations about mental disorder and people affected by them.

I think that the current version of the DSM is flawed in many ways and I think the new version will not be a great improvement (if it will be an improvement at all).

To achieve a more reliable diagnostic system it’s needed a more scientific approach, more studies investigating the validity of the proposed criteria that lead to actual changes in those criteria when changes are needed, more openness to independent scientific review, and also more contributions from outside the fortress of psychiatry : psychologists, for example, could be a big step forward, but I think also to epidemiologists and neuroscientists.

Without a tremendous shift of approach, the DSM will remain an almost totally arbitrary cookbook of symptoms.

Maybe you have Asperger too.

Asperger’s Disorder is characterized by a severe and sustained impairment in social interaction, and restricted and repetitive patterns of behavior.

It is often present an inability to use non-verbal behaviors such as eye-to-eye gaze, facial expression and body postures, to regulate social interaction and communication. The failure to develop peer relationships appropriate to developmental level is another key feature of the disorder.

You can take a look here If you are interested in the “more specific” diagnostic criteria for Asperger’s Disorder. However, take in mind that for the upcoming new edition of the DSM, it was proposed that this disorder should be “subsumed into an existing disorder:  Autistic Disorder (Autism Spectrum Disorder)”.

According to the DSM-V, studies have not demonstrated the validity of the subtypes of DSM-IV, especially that of Asperger disorder. The main reason most studies have not been able to distinguish between Asperger disorder and autism is that the DSM-IV criteria were vague and difficult to use.

- Mohammad Ghaziuddin

For these vague criteria Asperger’s Disorder have an history of over-diagnosis.

Benjamin Nugent tells his story:

For a brief, heady period in the history of autism spectrum diagnosis, in the late ’90s, I had Asperger syndrome. […]

I exhibited a “qualified impairment in social interaction,” specifically “failure to develop peer relationships appropriate to developmental level” (I had few friends) and a “lack of spontaneous seeking to share enjoyment, interests, or achievements with other people” (I spent a lot of time by myself in my room reading novels and listening to music, and when I did hang out with other kids I often tried to speak like an E. M. Forster narrator, annoying them). I exhibited an “encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus” (I memorized poems and spent a lot of time playing the guitar and writing terrible poems and novels). […]

The thing is, after college I moved to New York City and became a writer and met some people who shared my obsessions, and I ditched the Forsterian narrator thing, and then I wasn’t that awkward or isolated anymore. According to the diagnostic manual, Asperger syndrome is “a continuous and lifelong disorder,” but my symptoms had vanished. 

He was diagnosed when he was 17, but later, in his adult life it “became clear” that he didn’t have asperger’s disorder. He point out that: 

Under the rules in place today, any nerd, any withdrawn, bookish kid, can have Asperger syndrome.

The definition should be narrowed. I don’t want a kid with mild autism to go untreated. But I don’t want a school psychologist to give a clumsy, lonely teenager a description of his mind that isn’t true.

I recently have had an experience that made me think about this diagnosis. After a 7 days-long neuropsychological screening, the doctors said to the mother of a kid I know, that he needed to see an asperger’s specialist, to see if he has asperger’s disorder, or if he’s just shy.

When you can’t understand if a kid is just shy or if he has asperger’s disorder, there’s something wrong.

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