When I look at the creation of DSM-5 from the perspective of an ER Psychiatrist, I feel as if I've been left behind, disqualified, overrun by hobby horses.
Epidemiologists ride some; ivory tower denizens can be found astride others; bench scientists at NIMH a few lengths behind but threatening to make a late push; several from each group carrying the insurance industry and Big Pharma's agendas in their side saddles.
However you deconstruct this derby, though, we humble clinicians can be found trampled, face-down in the muck of the stable floor.
Say what you will about DSM-III and its offspring through DSM-IV-TR, they've been constructed in a practical and user-friendly way for clinicians. It's not at all evident that DSM-5 will be guided by the principles of clarity or user-friendliness.
Which aspects of DSM-5 are most problematic for clinicians? In my opinion, diagnostic bracket creep and dimensionality top the list.
Will the "field tests" solve these problems before DSM-5 is published (we think) in 2013? In a word -- unlikely.
Three disclaimers here:
First, I might be a direct descendant of Emil Kraepelin. My mother's people escaped forced conscription under Otto von Bismarck in 19th Century Germany to become Minnesota sodbusters so there's a chance that Kraepelin may have been my third cousin, once-removed.
Second, I am a DSM-III guy all the way, having graduated from medical school and started a psychiatric residency in the 1980s. To me, Robert Spitzer and DSM-III rule, channeling Kraepelin, and it's hard to say whether much additional progress has been made from a clinician's perspective with the publication of DSM-III-R, DSM-IV, and DSM-IV-TR.
Third, I do not belong to the APA. I stopped paying dues about the year 2000 mostly because I was a tightwad. But, furthermore, I felt that the APA did not represent me well as a salaried public sector psychiatrist. It seems to be tailor-made for private outpatient psychiatrists and academic power players, but not so much for the rest of us.
My main complaint with DSM-5 is the problem of diagnostic bracket creep -- that is making patients of people who until the publication of DSM-5 would have been considered normal. A prime example of this is the "Psychosis Risk Syndrome."
The researchers involved are not bad people, but they can certainly be found guilty of having good intentions -- and you know where those lead. They would like to identify adolescents and young adults at risk of developing schizophrenia and to intervene early. This sounds like a reasonable idea and one quite worthy of ongoing research.
The problem is that such an exploration belongs in the DSM's appendix, an area created by prior authors of DSM-III, represented by Dr. Robert Spitzer, and DSM-IV, headed by Dr. Allen Frances, to identify diagnostic areas in further need of research. It would be premature to place this category in the official taxonomy.
Among other things, dimensionality is operationalizing things that ought to be in the purview and education of clinical psychiatrists -- and that is constructing a thorough history of present illness and review of symptoms during the clinical interview and write-up. I'm an old-fashioned narrative kind of guy and I feel as if things like anxiety, sleep patterns, energy, appetite, presence or absence of psychotic symptoms, presence or absence of substance use, and current psychosocial stressors should be routinely found in a "write-up." A comprehensive story needs to be told and these variables need to be covered.
For example, take the group headed by Professor Jan Fawcett in assessing suicide risk. This group has performed a very important public service by poring over studies to identify the most important risk factors of suicide. As an ER psychiatrist, I can tell you that suicide risk assessment is one of the most important parameters of a clinical evaluation.
But I'm here to tell you -- this information does not belong in a "diagnostic" manual. Suicidal ideation or suicide plans or intention or a suicide attempt are NOT diagnoses. Suicide risk runs through disorders of mood, thought, substance, personality, anxiety, etc.
Suicide risk IS an important clinical phenomenon and it needs to be covered thoroughly in things like textbooks and clinical practice guidelines. A suicide risk factor scale belongs in the appendix of a DSM, but not in the body of the DSM itself.
And this brings us to another criticism of the DSM, which I think has some merit. It's NOT supposed to be a textbook even though it often reads like one (and this does go all the way back to the 1980 publication of DSM-III.)
So, save the appendix! But continue to keep it separate from the diagnostic categories.
Okay, maybe I'm just being a curmudgeon. But I think DSM-5 should be user-friendly to front-line clinicians, whether or not we choose to belong to the APA. I find DSM-III et al to be reasonably user-friendly and frankly not too bad of a textbook on psychiatric taxonomy (but not so much on performing a psychiatric evaluation or guiding psychiatric treatment.)
While many observers have accused the APA (American Psychiatric Association) as being motivated by greed in its crafting of a new DSM, I prefer to look to another one of the Seven Deadly Sins, hubris, as the prime motivation for many of its architects.
And the transportation of choice for the prideful jockey?
The hobby horse, of course.
copyright Paul R. Linde, M.D.
