Skepticism and DSM: Kate Donovan

DSM is Diagnostic and Statistical Manual for mental illness: US based. At the moment we’re on the DSM V. There are links at Kate’s blog (Gruntled and Hinged).

DSM is made by APA, by a committee tasked with updating it. It’s atheoretical, so it’s just supposed to be a way to diagnose. No why or how to treat or prevent. It’s the main way insurance is provided.

Ideally DSM should classify all mental disorders known to exist. This is tricky. Prior to 1973 homosexuality was considered a mental disorder: this wasn’t changed based on scientific consensus, rather just by the committee.

DSM is sorted into four Axes. Axis 1 is all mental disorders (previously personality disorders were in Axis 2). Other axes are functioning, other contributing factors, or health. We’ll be looking primarily at Axis 1.

Diagnoses are supposed to be reliable and valid. Reliable=if you see multiple psychiatrists and get the same diagnosis. Valid is whether or not diagnosis accurately reflects what is happening. This can get a little circular. These two characteristics can vary quite widely.

The DSM gets criticized for looking at superficial symptoms: there is a lot of self-report, but that means all we get is what’s reported not what’s going on in the brain. We don’t know if causes of similar symptoms are always the same.

Different diagnoses in the DSM have different amounts of research backing them. Some are strongly supported w/research, others not. The amount of research can affect reliability and validity.

There have been some concerns that the DSM is too influential. Should we allow the DSM to determine our research, treatment, etc?

Question: how can laypeople influence the DSM?

Prior to DSM 5 they released edits and allowed public to comment.

Comorbidity problem: comorbidity=multiple diagnoses. E.g. many people with anorexia also have depression. Concern is what if part of having anorexia is having symptoms that look like depression? OR do you have two separate mental illnesses inhabiting one brain? Many mental illnesses overlap quite heavily. This requires lots of research, but research is easier when patients only have one diagnosis.

Personality disorders: many people were meeting criteria for multiple disorders. This is a problem because personality disorders are supposed to be overarching patterns that show up through all areas of life?

New update: 6 disorders, but add Trait Specified Personality Disorder: meeting criteria subthreshhold for many disorders. Unfortunately this was too complex for institution. This is included under review.

It’s really hard to research personality disorders because people are not inclined to say their personalities are a problem. Generally the people who get a diagnoses come in through criminal justice or because of family and friends. It’s likely the people we see with them are the ones who have very severe versions.

Personality disorders are a place where skepticism is needed, but we should cut the DSM some slack due to the difficulty of getting research.

Eating disorders: Previously the DSM was not doing well and are greatly improved.

First with anorexia, refusal to eat was a criteria. That implies intent in ways that for an atheoretical diagnosis were problematic. This has been changed to talking about caloric intake. Another criteria was amennhorea which was not having a period. This left out lots of people who can also have eating disorders. This criteria was entirely dropped. One of the ways research is influenced by the DSM is that you use the DSM’s diagnosis for a disorder that you can use to research. This might create an incorrect participant pool.

Bulimia’s criteria previously required binge eating and compensatory behaviors happen twice a week, now it’s only once a week. Most of us would agree that binge and compensation once a week for months is disordered.

Places the DSM could improve is that people bounce from diagnosis to diagnosis all the time. This is not something you want to see.

Binge eating disorder was included in DSM IV as a diagnosis under review and it has been included in DSM V.

Depression: this is a story of getting useful criteria fine-tuned. We’ve got lots of tests for diagnosing and lots of treatments. From DSM IV to DSM V there was controversy over whether someone with grief could have depression. This is where neuroscience can help.

One reason we get this fine tuning is because of the prevalence of depression. Depression is also getting slightly more accepted than other mental illnesses, so people are more able to speak about their depression or be open to seeking treatment.

One area for skepticism is that we have so many treatments that only work sometimes for some people. Treatments also take time and people with severe depression don’t necessarily have the option of waiting to get better. This suggests different causes that all look like depression.

Problem of overdiagnosis: this is one way that people are denied treatment. But it’s still something to talk about: if we’re overdiagnosing that means research participants who may not actually have the disorder being researched. This also combines with problems getting access to treatment unless you have diagnosis. This is particularly a problem with kids: the way that you access school services is by having a diagnosis. We shouldn’t demonize those who pursue this as an option.

Kate’s Wishlist: More information spread about reliability of diagnoses. Therapy should not be predicated on diagnoses. Neuroscience should inform how we diagnose more.

Question: Given all the distrust about the DSM, what are some strategies for communicating its positives?

Work on talking about things like reliability and the process, talk about how to contribute. Psychology needs to do better at addressing not just the WEiRD populations, but research more than just the college sophomores in Psych 101. This will also help future psychologists recognize that others are not just like them. We need more diversity in the field.

Question: Any chance environmental stressors could be addressed?

This is part of the other axes in the DSM. Yes, when you are evaluated, one of the things to address is environmental and life stressors. From Ozy Frantz, it’s important not to just dismiss environmental stressors: e.g. a lot of people in grad school have anxiety. Anxiety is a natural response to the stress of grad school. But should we dismiss this anxiety because people are in grad school? No. If you need therapy and meds to help you get through the environment, then that’s ok.

Question: What do you think about programs that will not take patients with addictions?

Kate doesn’t like these. She understands that sometimes funding is an issue here, and recognizing comorbidity can be a very important thing here. On the other hand, taking patients with addiction and not treating the addiction is also a problem.

Question: Do you think the DSM V is better in general than DSM IV TR?

Yes along most axes. There are some specific diagnoses she’s really not a fan of. Overall it’s better. There is more evidence, the improvements are important, but some of the specific changes are bad.

Question: Could you comment on the DSM as an insurance document and how it will change in the future?

Kate knows that it’s used for coding and to explain how you enroll in specific programs. She doesn’t know if it will change, but she’d like it to.

Question: What diagnoses do you think don’t have specific support but are still in the DSM?

Multiple Personality Disorder is a risky thing, but we need more evidence for it as a non-cultural phenomenon. There are some things Kate’s not willing to get into the controversy publicly.