Archive for the 'DSM-V' Category

Proposed DSM-5 Cultural Formulation guidelines: A report from the SSPC

Last week saw the annual meeting of the Society for the Study of Psychiatry and Culture (SSPC) in New York City. SSPC’s mission includes “furthering research, clinical care and education in cultural aspects of mental health and illness,” and although somewhat small includes some of the most prominent thinkers in the world of psychiatry and culture. These are the people who go beyond simplistic cultural diatheses (e.g., individualism versus collectivism), incorporating multidimensional frameworks that include political factors as well as ethnicity and race.

Among the livelier presentations was a report by Roberto Lewis-Fernandez, Neil Aggarwal (both at Columbia), Laurence Kirmayer (McGill), and Renato Alarcón (Mayo Clinic and Universidad Peruana Cayetano Heredia) on much needed updates to the Cultural Formulation guidelines in the upcoming DSM-5. The DSM — Diagnostic and Statistical Manual — is the American Psychiatric Association’s official guidebook to human psychopathology, and the current version, DSM-IV-TR, is largely accepted as the last word on mental health problems in psychiatry, psychology, social work, and related disciplines. Cultural Formulation guidelines are suggestions for how clinicians should conceptualize the role of culture in patients’ mental health problems. The guidelines appeared first in the pages of the DSM-IV (1994), but, along with a short and messy list of “Culture-Bound Syndromes,” were placed in the back of the book where few practitioners would ever find them.

This time around there is a widespread effort to place the Cultural Formulation front and center in the DSM-5. Drs. Lewis-Fernandez and Aggarwal reported on a tool designed to make cultural formulation quicker and easier, the Cultural Formulation Interview, or CFI. The CFI is meant to be administered during patients’ initial assessment, and consists of 14 questions. Many of these questions are just good clinical practice. For instance, the first question is, “What problems or concerns bring you to the clinic?” Although there are hints at what might be considered culture by question three (“People often understand their problems in their own way, which may be similar or different from how doctors explain the problem. How would you describe your problem to someone else?”), it’s not until the seventh question that culture is explicitly mentioned: “Is there anything about your background, for example your culture, race, ethnicity, religion or geographical origin that is causing problems for you in your current life situation?”

The point of framing the questions this way  is to not make a big deal of culture while at the same time getting a good person-centered assessment that considers culture as important to how patients view their problems. This is meant to avoid the stereotyping that considering culture often leads to in situations in which clinician and patient differ on some cultural dimension. The CFI seems to provide space for individuals to define their problems as they see fit — i.e., to make explicit their own explanatory models — and then relate this to how others within their social networks (including family members and those that don’t share their culture) may see their problems.

My favorite exchange came after one audience member looked over the CFI and asked, “For whom would these questions not be relevant?”

Dr. Lewis-Fernandez replied: “Yes, exactly.”

The CFI is currently undergoing field trials. Read more about the proposed DSM-5 Cultural Formulation and the CFI, and express your opinion as to whether it should be emphasized (or not, I suppose), by following this link to the DSM-5 commentary website. Common sense needs advocates.

On a related note: If you haven’t read it yet, Allen Frances’ Op-Ed in Saturday’s New York Times, provocatively titled Diagnosing the DSM, is worth it. In it Dr. Frances, one of the architects of the DSM-IV, argues strongly that the DSM-5 development process should be untethered from professional psychiatry in order to build a better product. A teaser:

Until now, the American Psychiatric Association seemed the entity best equipped to monitor the diagnostic system. Unfortunately, this is no longer true. D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription. The association has been largely deaf to the widespread criticism of D.S.M.-5, stubbornly refusing to subject the proposals to independent scientific review.


Depression, grief & the DSM5

In the opinion pages of today’s New York Times the former chairman of psychiatry at Duke and DSM-IV architect Allen Frances writes a passionate plea to the architects of DSM5 not to inadvertently medicalize normal grief. Although I’d made a promise to myself not to keep referencing major press outlets in the blog (because everyone has access to them), this one was too good to pass up. The controversy surrounds the loosening of the criteria for what counts as Major Depressive Disorder (MDD) — what we in mental health call depression. Frances points out that in drafts of the DSM5, if normal grieving (e.g., following the death of a loved one) carries on for more than two weeks, the person grieving would be diagnosable with MDD.

What would this mean? Well, for starters, it would be a windfall for pharmaceutical companies. But no, there’s no real conspiracy here. As Frances explains:

It is not that psychiatrists are in bed with the drug companies, as is often alleged. The proposed change actually grows out of the best of intentions. Researchers point out that, during bereavement, some people develop an enduring case of major depression, and clinicians hope that by identifying such cases early they could reduce the burdens of illness with treatment.

Ah, good intentions… This is a good example of a fine line that comes up often in mental health: that  between prevention and over-diagnosis. If the discussion at this year’s American Psychiatric Association meeting is any barometer, this is a major discussion within the various groups designing DSM5. We want to catch mental illness before it becomes full-blown, but we also don’t want to diagnose someone who is sad or troubled for really good reasons and will heal on their own (and maybe even grow out of their grief). Frances:

The bereaved would also lose the benefits that accrue from letting grief take its natural course. What might these be? No one can say exactly. But grieving is an unavoidable part of life — the necessary price we all pay for having the ability to love other people. Our lives consist of a series of attachments and inevitable losses, and evolution has given us the emotional tools to handle both.

… Humans have developed complicated and culturally determined grieving rituals that no doubt date from at least as far back as the Neanderthal burial pits that were consecrated tens of thousands of years ago. It is essential, not unhealthy, for us to grieve when confronted by the death of someone we love.

I think here Frances misses something (or at least here he misses something — he’s a pretty smart guy, so he probably doesn’t really miss this): taking medication for sadness and stress has become a “culturally determined grieving ritual” for many people in the US. Does that mean that we should accept the medicalization of normal emotions? Of course not. It only means that we should recognize that for many, it has become part of our culture, and turning the tide will take more than rewriting drafts of DSM5.

Brain-mind or heart-mind; TMS or MST; DSM-5 or DSM-V? The American Psychiatric Association in New Orleans

This weekend and the first part of this week the American Psychiatric Association held its annual meeting in New Orleans, LA. In addition to staying out of the way of drifting gulf oil and seeing a lot of great music, I sat in on a few sessions in the monstrous Morial Convention Center to hear the latest from my psychiatric cousins. Psychiatrists in general fascinate me. On the one hand they rely heavily on the biomedical model to explain psychological phenomena (they are, after all, doctors), on the other they talk even more impressionistically than my psychologist compatriots (one of the presentations this year is on Chopin). As doctors, they know so much stuff (doctors have to memorize an amazing number of facts about the body), yet as researchers they can hardly handle more than two-by-two tables in their analyses (to be honest, most psychologists don’t do a whole lot better — they just don’t get published). I get asked all the time whether I’m a psychologist or a psychiatrist, and then, regardless of the answer, if I can prescribe; for those of you wondering: psychologist, and no.

On Saturday, I attended a session run by Devon Hinton (of Mass General) on cultural assessment of non-Western patients. In addition to Devon, his brother Ladson, Roberto Lewis-Fernandez, and myself, Brandon Kohrt of Emory University presented a paper on culture and symptoms. Brandon’s done a lot of work with child soldiers in Nepal, and presented on “child-led indicators” of distress among this population. Lots of good things in there, but my favorite was a distinction made among Nepalis between problems of the “brain-mind” and problems of the “heart-mind.” Your heart-mind is where your emotions are, your brain-mind where your thinking and cognition happen. Heart-mind problems are normal, brain-mind problems stigmatized. Although heart-mind problems can lead to brain-mind problems, they usually can be addressed successfully with appropriate social support. Critically, Brandon reported that Western psychosocial NGOs working with Nepalis affected by the civil war (which ended in 2006) had translated posttraumatic stress disorder into a term associated with brain-mind problems, and thus found it very hard to get people to participate in their interventions. It was only when they started using a heart-mind term that they got more people to participate.

TMS stands for transcranial magnetic stimulation. MST stands for magnetic seizure therapy. I’ll admit here that I am way out of my league here, but I’ll give you the synopsis. Both are new treatments for depression, and both involve magnets applied to your skull (falling under the somewhat euphemistic category of “brain stimulation”). In TMS you are awake, in MST you are under anesthesia. Okay, why do you want to do either of these things? Well, the treatment with the strongest therapeutic effects on people who have suffered multiple bouts of severe depression is well known to be electroconvulsive therapy, ECT. Yes, that means administering electric shocks to people’s brains. The problem with ECT is that associated with shocking people’s brains is some retrograde amnesia. So, electrotherapists have searched for more focal treatments at lower doses, and have found some success by putting strong magnets on the surface of people’s heads. I’m being a bit glib here, but really, this is pretty exciting stuff — particularly for those suffering from depression that is resistant to medication. For more on TMS, see the work of William McDonald; for MST, see Sarah Lisanby (she’s also done TMS work as well).

The development of DSM-5 was a big topic at APA 2010. The publication of the DSM-5 in May of 2013 (at APA San Francisco) is already a much-heralded event, and those on the various subcommittees have been doing due diligence throughout the various mental health conference circuits. I heard a lot about DSM-5 at APA 2010, but perhaps the most interesting proposed conceptual change I heard was the decoupling of disability from the notion of mental disorder. Since DSM-III (1980), criteria for diagnosing most disorders has included a functional criterion; i.e., you can’t just have some symptoms, the symptoms have to keep you from doing the things you want or need to do. So, someone with depression who is really sad but gets everything done cannot really have clinical depression. Decoupling symptom criteria from functional disability would put DSM-5 in line with the World Health Organization’s ICD-10/ICF system (ICD-10 is the WHO’s classification disorders manual; ICF is their functional disability manual). It would also clearly expand the number of people with disorders, as the functional criterion limits the application of a given disorder. Over-diagnosis will likely result. However, leaving things as they are means that the functional criteria limits prevention efforts: if you have to wait to diagnose a disorder before it becomes disabling, how can you administer (or more to the point, how can you pay for the administration of) prevention efforts? Stay tuned… or just check out the DSM-5 website. (By the way, it’s settled: DSM-5, not DSM-V.)

Louis Menand in the New Yorker on depression and therapy: Mental health as science? Science as science?

In this week’s New Yorker, Louis Menand writes eloquently about depression, psychotherapy, psychopharmacology, and our American culture. Although as a journalist he glosses over a few complex issues, for the most part he presents them with impressive clarity and even a history lesson (re valium in the 1970s and ’80s). Here’s a teaser:

The position behind much of the skepticism about the state of psychiatry is that it’s not really science. “Cultural, political, and economic factors, not scientific progress, underlie the triumph of diagnostic psychiatry and the current ‘scientific’ classification of mental illness entities,” Horwitz complained in an earlier book, “Creating Mental Illness” (2002), and many people echo his charge. But is this in fact the problem? The critics who say that psychiatry is not really science are not anti-science themselves. On the contrary: they hold an exaggerated view of what science, certainly medical science, and especially the science of mental health, can be.

Mental health has come under fire recently, and Menand shows us why — but the conclusion is not as simple as it might seem.

Debate over DSM-V reveals mainstream mental health is now worried about overreaching

The draft of DSM-V is out for review, and it’s garnering some attention. Wednesday’s story from the New York Times made it to their top ten stories hit list, and last night the News Hour featured a moderately lively DSM debate (lively for PBS, only moderately so for psychiatrists) between Dr. Alan Schatzberg, who’s involved in developing DSM-V, and Dr. Allen Frances, who’s not but was involved in developing DSM-IV (the current edition). Among other disagreements between these two Alans, er, Allens, Allen Frances offered the following:

And we thought we were being really careful about everything we did, and we wanted to discourage changes. But, inadvertently, I think we helped to trigger three false epidemics, one for autistic disorder that you mentioned, another for the childhood diagnosis of bipolar disorder, and the third for the wild overdiagnosis of attention deficit disorder.

And my concern has been that the ambitions expressed by those working on “DSM-V” would lead to unintended consequences, with many patients being created through new categories or the lowering of thresholds of existing categories, people who probably don’t need the treatment that they might receive, but would probably receive if they get a diagnosis.

Later, Alan Schatzberg responded that members of the DSM-V development committee:

have been very careful to define the threshold for patients being in distress, being impaired, and being able to obtain or receive a diagnosis. We try to be — refine on those criteria from “DSM-IV” to make it tighter. In fact, I think “DSM-V” will reduce the number of patients who receive diagnoses.

Let’s take a moment here to think about what these guys are saying. I’m less impressed by what they said specific to “false epidemics” and tightening thresholds–although it’s pretty important–and more impressed by the larger, almost meta-admission that a major problem in mental health practice is that it has the power to pathologize what may be normal problems, and a troubling history of doing so. Although others have made good arguments that there are serious consequences when mental health overreaches it’s boundaries, it seems to me that these Alan/Allens’ admission signify a turning point. Up until recently, mainstream psychiatrists and psychologists have mainly tried to convince people that mental health problems are real, and that they are serious. Now it seems some are saying that mental health practitioners need to be a lot more careful about what they classify as disorder, as they have the power to do more harm than good if they push it too far. Of course, this is also consistent with the first rule of medical school: Above all, do no harm.

The draft of DSM-V comes at a time when American mental health is under attack. After several years of scandals involving prominent research psychiatrists in the pay of pharmaceutical companies, a few high profile studies suggesting that many people who get psychotropic drugs don’t really need them, and a number of disorganized psychosocial missions in disaster zones, releasing a new DSM is bound to be a controversial act. In this light, the committee’s decision to present a draft and solicit comment is a welcome measure. Although undoubtedly many comments will be of the Tom Cruise variety (google “Tom Cruise demeaning Brooke Shields for her post-partum depression” if you don’t know what I’m talking about), many will prove ultimately very helpful to the process. Review DSM-V and make a comment yourself, here.

PS: Note that some places refer to the new manual as “DSM5” rather than “DSM-V.” Which will win? Roman numerals are more stately perhaps (and consistent with DSM tradition), but DSM-V may run into the problem of getting mixed up with “DMV”–which would drive us all crazy.

The Da Vinci Code of DSM-V revealed Wednesday

The Diagnostic and Statistical Manual of the American Psychiatric Association, or DSM, is the compendium of mental disorders that psychiatrists, psychologists, and social workers use to describe the state of their patients, clients, and sometimes their family members (though they really shouldn’t). The DSM is currently in its fourth edition, “DSM-IV.” However, after over ten years of meetings, a fifth edition is on the way, slated for May 2013, a draft of DSM-V will be released this Wednesday, February 10.

There have been a few concerns about the DSM-V and even accusations from former APA directors that the process has been shrouded in secrecy, a veritable Da Vinci Code of psychiatry! Anyways, all will be revealed Wednesday. In addition to being based more on models suggested by empirical research (research based on disorders listed in the DSM-IV), word has it that there will also be a severity dimension for symptoms (currently symptoms are dichotomous), some sort of accommodation to the frequent comorbidity a disorders (e.g., the reported 80% comorbidity for PTSD with major depression), a “hypersexuality disorder” (oh my), and some reconceptualization of how to deal with those “culturally-bound syndromes” (see January 10 post) at the back of the book.

Here’s the news story from The Economist. Here’s the site for the DSM-V from the American Psychiatric Association.

March 2018
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