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Sunday, June 3rd 2012

The Rough Path of Defining Medicine In The Open

Suppose your spouse or child died two weeks ago and now you feel sad, take less interest and pleasure in things, have little appetite or energy, can’t sleep well and don’t feel like going to work. In the proposal for the D.S.M. 5, your condition would be diagnosed as a major depressive disorder.

Dr. Allen Frances, who wrote the DSM-IV, chastised the task force working on the upcoming DSM-V with the above words in the New York Times several months ago. Even I jumped in.

Other controversial proposals include dramatically redefining how autism is diagnosed and changes to the definition of alcohol addiction.

Many scholars believe that the new manual will increase addiction rates. A study by Australian researchers found, for example, that about 60 percent more people would be considered addicted to alcohol under the new manual’s standards.


Dr. [Charles] O’Brien, who led the addiction working group, has been a consultant for several pharmaceutical companies, including Pfizer, GlaxoSmithKline and Sanofi-Aventis, all of which make drugs marketed to combat addiction.

He has also worked extensively as a paid consultant for Alkermes, a pharmaceutical company, studying a drug, Vivitrol, that combats alcohol and heroin addiction by preventing craving. He was the driving force behind adding “craving” to the new manual’s list of recognized symptoms of addiction.

Why has there been so much outrage over the work of the task force for DSM-V? The open public comment on a draft of the work drew more than 10,000 comments form the public, the vast majority of them negative. To be fair rewriting the works which define medicine are always public jobs that draw ire, just look at work on the new ICD-10. But the APA task force behind the DSM-V seems to have put a number of bullets into their own foot and the way the APA has handled the public comment period has been less than ideal; the criticizers have run rampant in the media and the task force’s response has been slow and at times nonchalant and based solely on denial.

It is true that the public comments and criticisms have drawn changes, if not ideal ones then some, and I suppose that proves the system works. The definition of depression has changed and new diagnoses like attenuated psychosis syndrome and mixed anxiety depressive disorder have disappeared. Apparently enough for Dr. Allen Frances to say,

“At long last, DSM 5 is correcting itself and has rejected its worst proposals. But a great deal more certainly needs to be accomplished. Most important are the elimination of other dangerous new diagnoses and the rewriting of all the many unreliable criteria sets.”

I suppose, while the process works, it is a wonder why it was so particularly contentious this time. Granted the internet wasn’t what it is now back then but there didn’t seem to be such a large hoopla when the DSM-IV was being put out. Proponents of the work to date of the task force might say they are doing significant changes but just glancing through the proposals this seems more like moving from DSM-III to DSM-IV, not DSM-II to DSM-III. This isn’t an earth shattering proposal to redefine how psychiatry is to be practiced and how mental illness is to be diagnosed. Even that fact has drawn criticism. Criticism that the task force has missed an opportunity to rise to the next challenge in standardizing psychiatry,

The editors of the DSM-5 indicate that the new edition will provide new categories of disorders, alter some criterion sets, and emphasize matters of severity.4 But it will not divide psychiatric disorders into causally intelligible groups. Disregard for this issue — after 30 years’ experience with an appearance-driven policy — makes these proposed changes for the DSM-5 seem small. The big question — “What are these disorders?” — will remain unaddressed.

This mess seems mostly just the task force stepping all over their own feet and failing to rise to the occasion of the first DSM rewrite in the age of increased scrutiny.

And with that I’m out and off back to skim the proposals and self diagnose myself with a plethora of mental illnesses.