Treatment guidelines to go ‘on the couch’

Dr John Wallace examines the proposed changes in the draft criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders

The Economist magazine has suggested that spring could be a time for the world of psychiatry to lie on the couch and examine the state that it is in. This suggestion was prompted by the publication by the American Psychiatric Association (APA), on 10 February, of a draft of its new diagnostic criteria for mental illness.
The proposed fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has provoked some controversy. This is understandable when you think about it, as DSM-5 is seen as attempting to classify disorders of what people regard as being most precious to them, their thinking and mood.
The first version of DSM in 1952 listed a number of psychological disorders and the symptoms used to classify them. The manual is important because, in the US where it is widely used, it impacts on whether someone will be diagnosed as having a disorder, and if so, what type. The whole purpose of diagnosis is to guide treatment, so it influences what treatment you receive, such as a mood stabiliser for bipolar disorder or cognitive therapy for depression. Indeed, it may decide if your insurance company will pay for your treatment in the first place.
The divided self
The manual is widely used by researchers to focus their research, but more importantly the DSM shapes how a psychiatric disorder is perceived by the person in the street. This new draft then is of considerable significance. The Economist points out that the proposal has stirred up latent fears, with some individuals accusing the APA of excessive secrecy in the development of the draft, and also of being over-ambitious in the changes it wishes to implement.
The proposed diagnostic criteria will be available for public comment until April 20, and, no doubt, many will peruse the document to see if their concerns are justified.
Psychiatry is made up of three main strands – physical, social and psychological – and each of these elements, in reality quite complementary, can at times appear to be in conflict with the others, with one appearing dominant at any given time. This is the case with the DSM, with the original appearing psychodynamic, as the theories of Carl Jung and Sigmund Freud were popular at the time that it was devised.
DSM-III, which was published in 1980, had a more ‘physical’ approach, and viewed the various psychiatric disorders as amenable to rigorous classification, just like diabetes or tuberculosis. Psychiatry continued to remain one of the Humanities but with a significant scientific input: a form of scientific bedside medicine.
Science not art
DSM-IV, which was published in 1994, increased the number of diagnosable disorders, but left the underlying ‘medical’ emphasis alone. The new DSM-5 proposes to recognise that many conditions, in their symptoms and perhaps genetic basis, overlap. It also intends to introduce an estimation of the severity of the condition, such as depression, into the mix. This is something we already do here in Ireland where we tend to use the European classification system that grades depression on the basis of mild, moderate or severe, Dr David Kupfer, Chairperson of the DSM-5 task force states that: “Dimensional assessments represent an important benefit for clinicians evaluating and treating patients with mental illness.” They can lead to earlier effective treatment and can help evaluate whether a patient is improving, as severity decreases.
Criticisms by classifiers associated with previous versions of the DSM claim that the new version will add too many new categories, now encompassing too many individuals who previously thought of themselves as statistically ‘normal’.
Accusations have been made that that the devisors of the new DSM have been disconnected from outside prevailing opinion. Also, individuals fearful that their particular behaviour may now be regarded as a ‘condition’ or ‘disorder’, want the DSM to be less judgmental and more respectful of their preferences, especially in the area of gender identity.
Science based, patient focused
The devisors of the new DSM are proposing that a single diagnostic category, ‘autism spectrum disorders’, will include Asperger’s disorder, and they are changing the term ‘mental retardation’ to ‘intellectual disability’, in keeping with a long tradition in psychiatry of changing terms when they take on a pejorative meaning. The devisors of DSM-5 are eliminating the category of dependence so as to better differentiate between the compulsive drug-seeking behaviour of addiction and the experience of ‘discontinuation’ symptoms associated with coming off certain prescribed antidepressants.
Internet addiction is not to be included as a category as they felt that there was insufficient research evidence to do so. They are, however, considering introducing an important ‘risk syndromes’ category to help clinicians identify the important early stages of some very serious conditions, such as emerging psychosis and dementia.
This will facilitate early intervention to improve the prognosis of some disabling disorders such as schizophrenia that are such a life-long burden to patients and their families.
The umbrella term, ‘eating disorder’ sees the new recognition of binge-eating disorder, as well as improved criteria for diagnosing anorexia nervosa and bulimia nervosa. In the process of devising the draft, the study group has attempted to be sensitive to the ways in which gender, race and culture affect the expression of symptoms and diagnosis of illness.
They had a specific study group research these issues to ensure that they were taken into account in the development of the diagnostic criteria. Task-force nominees were also screened for potential conflicts of interest.
The evidence pipeline
The APA responded to criticisms of the draft by stating that it had spent ten years in reviewing the whole area of classification and that the proposal published on February 10 was very much a work in progress. It is inviting the public to comment on the document on www.DSM5.org and the proposed diagnostic criteria will then be tried out in real-life settings.
The final diagnostic criteria will be published in May 2013, taking into account comments from the public and the results of the field trials.
This all seems eminently reasonable? The highly-respected Dr Kupfer believes that the process of developing DSM-5 continues to be deliberative, thoughtful and inclusive. The process, he says, is ‘based on the best science available’ including reviews and meta-analysis.
The ‘agenda is to expand the scientific basis for psychiatric diagnosis and classification’. And this is the crux of the matter. Many people have significant reservations about this scientific approach to medicine, and to psychiatry in particular.
Some want an ‘emotional’ solution to emotional problems and reject the idea that behind every twisted thought is a twisted molecule.
Others favour intuition and gut feeling over the ‘cookbook’, ivory-tower approach to individual problems that appears to favour detached number-crunching over compassion.
However, as Einstein said, behind every complex problem is a simple solution, which is usually wrong. Medicine in general, and psychiatry in particular, is littered with well-meaning, unscientific solutions that, at the very least, were unhelpful to the patient.
Early researchers into treatments such as cognitive therapy for depression specifically single out the lack of any agreed method of diagnosing depression as the main obstacle to the development of an effective psychological treatment for a disabling condition that affects a wide range of individuals, from politicians to fashion designers, sometimes with particularly adverse consequences.
l Dr John Wallace is a PhD reader in evidence-based medicine with Oxford University, investigating barriers to knowledge transfer from research to clinical practice.