Monday, December 20, 2010

More on SIAD

The DSM-5 Sexual Dysfunctions Subworkgroup is currently proposing to merge (Female) Hypoactive Sexual Desire Disorder (HSDD) and (Female) Sexual Arousal Disorder, and make a new diagnosis, Sexual Interest/Arousal Disorder (SIAD). I have previously reported on this and on commentary and criticisms on this proposal (here, here, and here). A couple months ago, another commentary was published in Archives of Sexual Behavior: Should Sexual Desire and Arousal Disorders in Women Be Merged? (So far, ASB has published a number of commentaries on proposed changes to the paraphilias and at least one about proposed changes to Gender Identity Disorder, but this is the only one about the sexual dysfunctions, presumably because a number of commentaries have been published in the Journal of Sexual Medicine.)

Recently, a response has been published--Should Sexual Desire and Arousal Disorders in Women Be Merged? A Response to DeRogatis, Clayton, Rosen, Sand, and Pyke (2010) by Lori A. Brotto, Cynthia A. Graham, Yitzchak M. Binik, R. Taylor Segraves and Kenneth J. Zucker--that I wanted to draw interested readers' attention to.

In reading the commentaries about this proposal a curious observation that I couldn't help but make is that there appears to be a rather strong correlation between supporting the merger and lack of pharmaceutical connections. It troubles me, but it's hard not to notice.

Brotto et al. address a criticism that the new proposal is based on expert consensus rather than data:
There is simply no justification for asserting that the proposal for Sexual Interest/Arousal Disorder was based on‘‘theoretical speculations or expert opinion.’’ Comprehensive and critical reviews of the empirical literature were undertaken (Brotto, 2010;Graham, 2010)and these formed the basis for the proposals. It should also be noted that the DSMIV-TR diagnoses of HSDD and FSAD were not based on any systematically collected body of data. The diagnosis of HSDD was the result of the expert opinion of Helen Singer Kaplan and Harold Lief: FSAD appears to have initially resulted from the early theorizing concerning the human sexual response cycle by Masters and Johnson and was probably saved from extinction by the hope that PDE-5 inhibitors would be effective for women.

They then make a not-so-subtle suggestion of industry based motivation for criticism:
In their letter, DeRogatis et al. reported on data from two nontreatment studies funded by Boehringer Ingelheim (BI).
and then later
Similarly, in DeRogatis et al.’s analysis of baseline data fromthreeBI-funded clinical trials of flibanserin

I counted no few that 5 references to BI having funded relevant studies.

And then their ending:
The basic pre-requisites for any clinical category include demonstrations of diagnostic reliability and construct validity. In fact, there are no published reliability studies for either HSDD or FSAD. We doubt that either diagnosis could withstand a serious reliability check. Considering that both of these diagnoses were created on the basis of expert opinion, have no efficacious treatments, and cannot be differentiated by current psychometrics suggests lack of validity. Other than habit, the motivation to preserve unreliable and invalid diagnostic categories escapes us. On the other hand, there is significant empirical evidence and theory, which we have reviewed, suggesting the overlap between current conceptualizations of desire and arousal. This evidence and theory has motivated our new diagnostic proposal to merge HSDD and FSAD. We hope that the clearly specified criteria for SIAD will motivate definitive studies to address this important diagnostic issue.

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