Wednesday, August 26, 2009

DSM-V News (or lack thereof)

A while ago, I wrote about the history of the diagnosis Hypoactive Sexual Desire Disorder and the involvement of the asexual community in trying to get the DSM-V to be more ace-friendly. I thought that I would highlight some of the more recent news with respect to the DSM-V that readers may be interested in.

To avoid having to write too much, I’m going to write relatively little and link a lot.

For some basic background, the American Psychiatric Association has a brief summary of the history of work so far and future plans: DSM-V: The Future Manual.

There are two main issues that I want to highlight: some sizable controversies over the DSM-V process and happenings with the Sexual and Gender Identity Disorders Workgroup. (The link is to a list of members with information about each.)

Robert Spitzer, chairman of the DSM-III and DSM-III-R taskforces, wrote a letter published in "Psychiatric News" in July 2008 called DSM-V: Open and transparent? in which he strongly criticized a policy in which all members of workgroups for DSM-V have to sign a confidentiality agreement which reads,
"I will not, during the term of this appointment or after, divulge, furnish, or make accessible to anyone or use in any way... any Confidential Information. I understand that 'Confidential Information' includes all Work Product, unpublished manuscripts and drafts and other pre-publication materials, group discussions, internal correspondence, information about the development process and any other written or unwritten information, in any form, that emanates from or relates to my work with the APA task force or work group."

A Response was published in the same issue.

More recently, another controversy has flared up in which a commentary by Allen Frances, chair of the DSM-IV taskforce, was published in the "Psychiatric Times" in July of this year: A warning sign on the road to DSM-V: Beware of its unintended consequences. Like Spitzer’s letter to the editor, the main criticisms deal with lack of transparency, lack of openness, and shortage of opportunity to get feedback. In a move that makes you go “Holy shit!!!” the DSM-V task force wrote a response in which they actually implied that his commentary was written out of financial motivation. That merited a response from Robert Spitzer (APA and DSM-V: Empty Promises) and, a few weeks later, a response from Frances. (Frances responds to APA: “Important Questions Need Answering) There have been a number of other brief commentaries that have resulted in the Psychiatric Times. (They have a number of articles linked under “DSM-V” and “Featured Articles.”)

One of the big criticisms is that no one really knows what the specific proposals that the workgroups are thinking about, leaning towards, etc. are, and there is fear that things will come as a big surprise at the end, after minds are made up, and without opportunity for feedback from those with a vested interest in the outcome. This criticism isn't entirely accurate, as has been pointed out in the responses to these criticsms: A number of members of the various workgroups present various proposals at conferences. On occasion, they may even post these online.

Turning attention to the Sexual and Gender Identity Disorders workgroup, this workgroup is subdivided into three sub-workgroups, based on the current three-way division of that chapter of the DSM. These sections are called Gender Identity Disorder, Paraphilias, and Sexual Dysfunctions.

As for the committee as a whole, they two progress reports have been posted online. One is from November 2008 and the more recent is from April 2009.

The question of how transparent the process is and how open to expert feedback they are seems to depend considerably on the individual subcommittee. The paraphilias people have presented the proposals they are considering at a number of conferences. Ray Blanchard gave presentations at the Society for Sex Therapy and Research annual meeting and at the WAS World Congress for Sexual Health about some of his suggested proposals, and these are posted on his webpage. (DSM talk at SSTAR, DSM talk at WAS.) There will be symposium on the matter at Association for the Treatment of Sexual Abusers’s annual conference. (This symposium will be on October 1.) They already have a document posted (Paraphilic Disorders and DSM-V: Considerations for Revision of Diagnostic Criteria) in which each member of that subcommittee has written a section about some of the changes they are considering.

Regardless of what one might think of any of their particular proposals, it gives a good idea of where they are in their considerations, and it enables people to provide feedback on those proposals. The other two subcommittees seem less transparent.

Regarding the diagnosis Gender Identity Disorder, a lot has been written, and here’s pretty much all I’ve been able to find out about the thinking of that subgroup, quoted from an article in MedPages Today about the APA’s annual meeting in May. (APA: Major Changes Loom for Bible of Mental Health
As described by its chairwoman, Peggy Cohen-Kettinis, Ph.D., of VU University in Amsterdam, the group is facing three main options: keep gender identity disorder approximately as it is, jettison it entirely, or change the name and diagnostic criteria.
Dr. Cohen-Kettinis said the group was nearing a decision, but both she and fellow group member Jack Drescher, M.D., a New York-based psychiatrist and prolific author on sexuality and gender, were noncommittal on which way the group was leaning.

As for the Sexual Dysfunctions, these seems to be less information than would be desired. The above cited progress report for April 2008 given information about who on the workgroup will present when at what conferences.

That sub-workgroup has four people. The chair is Taylor Segraves, who has been on the same subcommittee on the past few versions of the DSM. The other members of Irving Binik, Cynthia Graham, and Lori Brotto. At the already mentioned SSTR conference, there was a symposium for "Provisional Report by the DSM-V Workgroup on Sexual and Gender Identity Disorders." Information about the talks is found in the conference program, to which the following page numbers refer. Three of the members of the Sexual Dysfunctions subcommittee gave presentations (Segraves, Binink, and Brotto.) Segraves (pp. 40-41) discussed proposed changes to the diagnoses he was assigned (by himself?) to review: Premature ejaculation and male orgasmic disorder. Binik (pp. 44-45) discusses dyspareunia and vaginismus, which I assume are the diagnoses he has been assigned to write literature reviews for (given his area of research on the topic of his talk.) Brotto discusses reconceptualization of what are now hypoactive sexual desire disorder (for women) and Sexual arousal disorder (for women), though the abstract does not give much information on what specific changes are being suggested for DSM-V.

The other other talk listed on the April progress report was just recently given by Binik (Conference program p. 8). If I understand things correctly, this leaves only a vague idea for proposals for the future of (female) sexual arousal disorder and (female) hypoactive sexual desire disorder, and virtually no indication of what proposals they are considering for (male) hypoactive sexual desire disorder, sexual aversion disorder, and (male) sexual arousal disorder with the exception of what can be known from prior publications by members of the subworkgroup. (I use parentheses because the current system generally lumps male and female problems into the same category, following Kaplan's modification of Masters and Johnson's model for the sexual response cycle, which emphasized gender similarities and minimized gender differences.)

Particularly troubling, is that I can find nothing on what changes (if any) are currently being considered regarding the "clinical significance criterion" that is currently in each diagnosis. (That's the part that says something must cause "marked distress or interpersonal difficulty" to constitute a disorder.) These were added in a rather ad hoc fashion in DSM-IV and been a source of a fair amount of controversy. Yet I can find out nothing about what changes are under consideration regarding these.

What I've written and linked here is pretty much everything I've been able to find out online about the goings on, although there are some publications by subworkgroup members from before they were appointed to work on DSM.

Edit: My comments here have proved to be somewhat premature, especially regarding the lack of publicly accessible information about the thinking of the Sexual Dysfunctions Workgroup. For more information see News about the Sexual Dysfunction in DSM-V and more news.

1 comment:

Espikai said...

Thanks for the summary and the links. I've been trying to get a better understanding on the situation with the DSM-V, and this was very helpful. The whole thing seems to be a bit of a mess right now, unfortunately.