Saturday, February 26, 2011

Grandfathering in diagnoses

As people following the DSM-5 process know, both Robert Spitzer, chair of the DSM-III and DSM-III-R Task Forces, and Allen Frances, chair of the DSM-IV Task Force, have made severe criticisms of the DSM-5 process. Dr. Frances has since become very active, having a blog on the Psychiatric Times, which is also posted in Psychology Today. (DSM5 in Distress).

Responding to some of his criticisms, this years' first issue of the Bulletin of the Association for the Advancement of Philosophy and Psychiatry contained a number of authors' responses to these. The issue concluded with a brilliant and provocative piece by Dr. Frances, DSM in Philosophyland: Curiouser and Curiouser.

This article then served as the basis for this year's second issue, along with 22 responses, a response from Dr. Frances' to each, and some authors responding to his response. The whole thing is fascinating reading, if somewhat long.

One of the issues in this debate is whether to take a more conservative or a more innovative approach to change (i.e. how high of a threshold of support do we require for making changes?) Dr. Frances argues for a more conservative approach. When his arguments are applied to main disorders that mental health professionals deal with, I find his argument convincing. However, it has a serious problem that I felt hadn't been adequately addressed, and I emailed Dr. Frances about this issue. Resulting from this has been a dialog on issues very relevant to both HSDD and the paraphilias (the two parts of the DSM my own work has focused on.)

In A Conservative Approach to Diagnosis Grandfathers in Weak Links frames the issue by quoting my email:

A DSM critic, Andrew Hinderliter sent this perceptive email questioning the wisdom of the most fundamental decision we made in preparing DSM IV-- ie, our goal of keeping the system stable.

A problem with your conservative approach to psychiatric nosology is that it grandfathers in the good and the bad alike and provides no way of changing really bad parts of the system. Unquestionably, there are things in DSM that couldn't pass a risk-benefit analysis (the Paraphilia section is one example). In a previous email to me, you gave the following explanation for its continued presence in DSM-IV: "I think they are there only because of history and inertia, but these are powerful forces.' Quite possibly, the single most powerful force of diagnostic inertia in psychiatric nosology in the past half century was the strongly conservative approach to diagnostic change that you yourself chose to implement in DSM-IV. A conservative approach to diagnostic change has much to be said for it, but in all the arguments back and forth about it, I feel like there is an elephant in the room regarding the much-harder-to-justify diagnoses. I have no doubt that you've thought about this before, but I was just curious as to your thoughts on the matter.


Dr. Frances then discusses the issue, followed by a response from myself, and then a response from him. It's not a very heated debate, and his assessment (which I think is correct) is that:
Mr Hinderliter and I have no conceptual disagreement. We do, however, weigh differently the risks of diagnostic stability versus vigorous pruning.

Following up on this, is a second article in which Charles Moser, a long time advocate for sexual minorities and an internist committed to evidence based medicine, responded to the first article, and suggests a means for Solving The Problem Of Questionable Diagnoses Grandfathered Into DSM.

Moser writes:

Psychiatry, the APA, and the DSM editors should be dedicated to straightforward presentation of the facts (or lack thereof), exploring the problems with these diagnoses while adhering to the highest level of accuracy and completeness in reporting the data on which these decisions are made. Unfortunately, the DSM editors have not acknowledged any of the problems inherent in listing these grandfathered diagnoses in the DSM. Instead they keep suggesting that the DSM is a scientific document supported by an extensive empirical foundation. In fact, for some diagnoses (eg, the Paraphilias) there is minimal science to support inclusion, some studies refuting that they are even mental disorders, and serious risks attached to misuse.

All diagnoses should be subjected to a risk/benefit analysis and ideally the risk/benefit to the “patient” should take precedence over the risk/benefit to Psychiatry. For many of these grandfathered diagnoses, there is no clear benefit and many people so labeled have been harmed. The APA and the DSM editors should not need to be reminded that a guiding principle of all Medicine is “First, do no harm.” Ethically, the editors should explain the benefit and announce plans to limit the harm, or just remove these diagnoses. At the very least, the DSM editors need to minimize the potential harm from these diagnoses by acknowledging their problems and limitations.

There is a middle ground between continuing the status quo and complete removal. The DSM editors could acknowledge clearly which diagnoses do not meet the stringent criteria, either by creating and applying objective criteria or by creating a level of evidence system similar to those used evaluate medical interventions (for example, see http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm). Alternatively, they could drop the pretense that the DSM is a scientific document based on an extensive empirical foundation.


Dr. Frances' response is, to sum up:
Dr Moser offers an excellent idea, although one that has little chance of being accepted in the current climate and would be difficult to implement even under the best of circumstances...There are problems large and small. The immediate block to the implementation of Dr Moser's suggestion is the reluctance of the DSM-5 to allow open and independent review of any aspect of its work....Dr Moser's suggestion will likely fall on deaf ears and would be tough to accomplish-- but it is clearly the right way to go.

Recently, James Phillips has written a follow up: Solving The Problem Of Questionable Diagnoses Grandfathered Into DSM.

This post is already too long, so I'll have to continue my thoughts on the matter at another time. I encourage readers to go and read these! (If you can't read stuff on the Psychiatric Times page and don't want to sign up, you can read everything but Dr. Phillips' piece on via the Psychology Today link above.)

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