The Cycle of Classification: DSM-I Through DSM-5 - part 2

Blashfield, R. K., Keeley, J. W., Flanagan, E. H., & Miles, S. R. (2014). The Cycle of Classification: DSM-I Through DSM-5. Annu. Rev. Clin. Psychol, 10, 25-51

Allen Frances, M.D DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes.  https://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes

This is part two of the post the Cycle of Classification: DSM-I Through DSM-5  published on June 23, 2016.

DSM4

DSM4 was published in 1994.  A major change from previous editions was the inclusion of a clinical significance criterion to almost half of all the categories, which required that symptoms cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning".

DSM4TR

DSM4TR was published in 1994.  The diagnostic categories and most of the specific criteria for diagnosis were not changed in this edition.

In 2005 Sadler published an important and influential book titled "Values and Psychiatric Diagnosis".  Sadler highlighted five values and the roles they play in psychiatric nosology: (a) aesthetics—how people prefer things to be, in the sense that they “like” or “appreciate” them; (b) epistemology—choices about how we know what we know about classification (i.e., what research methods we prefer); (c) ethics—what morals the classification upholds; (d ) ontology—what is the fundamental nature of “things,” or in the case of psychiatry, what mental disorders are in a (meta)physical sense; and (e) pragmatics—how useful or user-friendly the classification might be. Until the publication of this book, most (although not all) of those assumptions were ignored or taken for granted. This book legitimized the imperative role philosophical discourse plays in the development of a classification of mental disorders.

DSM5

DSM5 was published in 2013, but the process of its development began in 1999.  Its drafts were published on an internet site, allowing people to remark and make suggestions.  The purpose of the DSM5 task force was to match the classification system to modern molecular biology, cognitive and affective neuroscience, and psychometrics.  The suggested categories were tested in eleven medical centers.  The total number of diagnostic categories in this classification system increased markedly. Most of this increase was in categories which covered a vast range of reasons why someone might be seen by a mental health professional (e.g., “overweight or obesity,” “problems related to unwanted pregnancy”).

The axes system that existed since the DSM3 was cancelled.  DSM5 has three parts:

Part one describes the structure of the DSM5.

Part two describes the mental disorder categories.  Significant changes in the fifth edition are the deletion of the subtypes of schizophrenia and the deletion of the subsets of autistic spectrum disorder.  The chapter that included disorders first diagnosed in infancy, childhood or adolescence was also deleted.

The third part introduces innovative models and measurement tools. Among them is an alternative model for personality disorders, which is a hybrid model (categorical and dimensional). There was a debate during the period preceding the DSM5 whether and how dimensional models of personality can be integrated into the DSM.  One of these models is the BIG5 model, about which I had briefly written before. 

Mental health professionals and the British Psychological Society argue that "normal" and "abnormal" personalities are not separate but exist on the same continuum.  It's possible to classify an "abnormal" personality by the same BIG5 factors.  It was suggested that the categories of personality disorders in the DSM5 be replaced by dimensional models of personality.  Blashfield and Keeley write that the political pressures against such a significant change were powerful, and the next version of the proposal involved a hybrid of categories and dimensions.  Some people argued that adopting a dimensional model of personality was not in the financial interest of the APA because copyrights for existing measurement instruments for these dimensions were held by others.

Other DSM5 criticisms:

The way the categories were built:  the DSM deals mainly with the symptoms of mental disorders and not with their causes.  It classifies disorders based on statistical or clinical patterns.  This method can cause the classification of people who have the same symptoms for different reasons or due to different causes into the same category.  This encumbers research efforts.  But what's the alternative?  I'm not sure we have enough knowledge to enable us to classify mental disorders according to their causes.

Over-diagnosis and medicalization of normal life situations:  some professionals argue that the great increase in the number of diagnostic categories reflects and causes an increased medicalization of human nature, and may cause over-diagnosis of mental disorders.  One of the people arguing this is Dr. Allen Frances, the head of the task force of the DSM4.  He argues that normal life situations, like temper tantrums or natural grief, become mental disorders in the DSM5. 

  

The extent to which the DSM structure is in line with the way clinicians diagnose in real life: Research about the way experienced clinicians make diagnostic decisions show that they are not using criteria lists.  Instead they compare the new patient with patients they have seen previously using a prototype.  Thus some professionals argue that the DSM diagnostic criteria fit research more than clinical practice (but see one of the previous points…).   Blashfield and Keeley suggest that prototypes would be a better way for clinicians to learn and communicate diagnostic categories once the categories are well defined with feature lists (i.e., criteria).

The DSM5 writing process:  controversy erupted over the potentially secretive process that was being used to make decisions as well as the corrupting influence of income and the DSM's potential revenues. More than once, important decisions that affected the final outcome of a DSM categorization system were made at the level of the Board of Trustees of the APA. 

Blashfield and Keeley recommend that the APA make all financial records about the DSM, both past and present, publicly available. This would include information about royalties (if any) and honoraria paid to individuals involved with these editions and funding from pharmaceutical or other companies that could experience a financial impact because of DSM-influenced decisions.  

The Cycle of Classification: DSM-I Through DSM-5 - part 1

Blashfield, R. K., Keeley, J. W., Flanagan, E. H., & Miles, S. R. (2014). The Cycle of Classification: DSM-I Through DSM-5. Annu. Rev. Clin. Psychol, 10, 25-51.‏

The struggles and controversies surrounding mental disorder definitions in the various DSMs remind me of the struggles surrounding learning disability definition.  This is one of the reasons it's good to know them.

DSM = Diagnostic and Statistical Manual of Mental Disorders

This paper reviews DSM development. The paper uses the term "patients" to describe people in need of psychiatric intervention and, thus, DSM definitions.  I'll use the term "patients" in this post following this paper.  The way we name or refer to our customers reflects a value judgement, to my opinion (I prefer to call them "clients").  This is also the case with the way we name our clients' problems (this paper names them "mental disorders").

Here are some interesting points from this paper.

We begin with this fascinating table:

NAME	PUBLICATION YEAR	NUMBER OF PAGES	NUMBER OF DIAGNOSTIC CATEGORIES	PRICE IN DOLLARS	REVENUE FOR THE AMERICAN PSYCHIATRIC ASSOCIATION IN MILLIONS OF DOLLARS
DSM1	1952	132	128	3$	UNKNOWN
DSM2	1968	119	193	3.5$	1.27
DSM3	1980	494	228	31.75$	9.33
DSM3R	1987	567	253	NOT WRITTEN IN THE PAPER	16.65
DSM4	1994	886	383	$48.95	120
DSM4TR	2000	943	383	$74.95	UNKNOWN
DSM5	2013	947	541	$199	UNKNOWN

DSM1

Following the Second World War, there were four classification systems of mental disorders in the US.   The American Psychiatric Association (APA) decided to overcome this “Tower of Babel” situation by creating a classification that would be acceptable to all members of its organization and that could unify the diagnostic terms of its psychiatrists. The result was the DSM1.    DSM-I had a hierarchical system in which the initial node in the hierarchy was differentiating organic brain syndromes from “functional” disorders. The functional disorders were further subdivided into psychotic versus neurotic versus character disorders. This organization roughly followed the decision-making process of clinicians.

 The DSM-I descriptions of disorders were prose paragraphs that incorporated behavioral and trait-like criteria. The terms in the description were relative and left to the interpretation of the clinician, leading to problems with reliability across professionals.

DSM2

DSM2 published in 1968 was the result of an effort to unite the classification systems in the world.  It was organized in a similar way as the DSM1.  Many of the new categories added in the DSM-II were categories of relevance to outpatient mental health efforts.

In 1971 Kendell et al conducted a study in which a set of eight videotapes of patients from the United States and Great Britain were shown to groups of American and British psychiatrists. For all eight videotapes, the modal diagnosis by the American clinicians was schizophrenia. In contrast, some of the videotapes, in the opinion of the British psychiatrists, represented patients with manic-depressive disorders, schizophrenia, and personality disorders.   The results, that showed there are still differences in diagnoses between professionals in different countries, were considered as evidence that Americans tended to be over inclusive in their use of schizophrenia as a diagnosis.

In 1973 Rosenhan published a provocative paper in Science about how a group of colleagues went to different inpatient facilities in the United States requesting admission. They were truthful about themselves during the intake interview except for two things: (a) they gave fictitious names so that their admissions would not appear on their future medical records, and (b) they reported hearing a voice saying “Empty” or “Thud.” All were admitted with a diagnosis of schizophrenia. Their average length of stay in the inpatient facility was nineteen days (the total range was 7 to 52 days). When discharged, most of them were given a diagnosis of “schizophrenia, in remission.” Rosenhan and his colleagues noted that most of the patients in the facilities spotted that they were fakes, but none of the pseudopatients were detected by the hospital staff. Rosenhan concluded that inpatient facilities of the time could not differentiate the sane from the insane.  Rosenhan’s paper stirred up a firestorm of reactions

.

These and other studies were stimuli for changes in the DSM3.   

DSM3

Publishing the DSM-III in 1980 was part of a paradigm shift in psychiatry (and the mental health field in general). Prior to the DSM-III, psychiatry was dominated by psychoanalytically trained psychiatrists. These psychoanalysts saw little value to clinical diagnosis for working with psychotherapy patients. In contrast, the main authors of the DSM-III attempted to bring psychiatry back to its medical roots. Their ideas fit well with the transition in treatment focus from psychotherapy to the use of medications.  

The DSM3 authors will to drop the term "neurosis" from the DSM raised a lot of controversy among professionals.  A compromised was reached in which the word "neurosis" appeared in parenthesis following the word "disorder" in specific cases.

Robert Spitzer, who was the head of the DSM-III and the organizing committee for the DSM-III took the bold step of proposing a tentative definition of the concept of mental disorder. They needed this definition because an explicit goal of the creators of the DSM-III was to avoid speculations about the causal mechanisms (especially theoretical concepts couched in psychoanalytic terms) that explained psychopathology. This definition was also in direct contrast to the antipsychiatry movement that attempted to define a mental disorder as society’s way of dealing with undesirable people—by labeling them with a mental disorder to keep them quiet and segregated.

The definition in the DSM-III was: Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is typically associated with either a painful symptom (distress) or impairment in one or more important areas of functioning (disability). In addition, there is an inference that there is a behavioral, psychological, or biological dysfunction, and that the disturbance is not only in the relationship between the individual and the society.

The DSM-III definition of mental disorder led to an interesting and growing discussion of psychiatric classification by philosophers, cognitive psychologists, social anthropologists, and historians.

The DSM-III contained diagnostic criteria to specify the meaning of the categories. In addition, for each category, there was a description of the typical demographic profile of patients experiencing this disorder, a lengthy prose explanation of what the category meant, a description of how to differentiate the target category from any other category with which it might be confused, and a brief discussion of what was known, if anything, about the course and onset of the disorder. Another innovation to the DSM-III was that the system was multiaxial. Each patient was expected to be diagnosed along five separate axes: (a) the descriptive presentation of the patient (i.e., the mental disorder categories), (b) the underlying personality and/or intellectual disorder, (c) any associated medical disorder that was relevant to the patient’s psychiatric presentation, (d ) the psychosocial stressors in the patient’s environment, and (e) the patient’s highest level of adaptive functioning in the past year.

 After the publication of the DSM-III, Spitzer and his colleagues created the SCID (Structured Clinical Interview for DSM-III-R).   By the year 2000 there were over 240 instruments to measure various aspects of psychopathology and mental disorders.  The reliability of diagnostic assessment using these new instruments generally was a distinct improvement over what had been found in the pre-DSM-III research. Spitzer & Fleiss’s (1974) review of pre-DSM-III reliability research showed estimates of interclinician agreement typically ranging from 0.4 to 0.6. Using structured interviews like the SCID, reliability estimates were distinctly higher, typically in the range of 0.75 to 0.90. Because of the clearly defined method for assigning psychopathology, along with improved reliability, structured interviews would soon dominate the research world although even today they are rarely used in clinical practice.

How reflective was the DSM3 structure of the "natural" way clinicians conducted diagnoses?

Cantor et al. (1980) had 13 mental health clinicians list the features that they associated with nine DSM-II diagnostic categories of psychosis. Any feature that was chosen by at least 3 of the 13 clinicians was kept for the final feature list. Then they took twelve case histories of patients that had been given one of four psychotic diagnoses (manic, depressed, paranoid schizophrenia, and undifferentiated schizophrenia). Four cases were considered to be quite prototypical of the four diagnoses (i.e., these four cases contain almost all of the features generated by the 13 clinicians), four were moderately prototypical, and four were not typical (i.e., these four cases had four or less of the defining features generated by the 13 clinicians). These case histories were given to the clinicians to diagnose. The reliability of the diagnoses varied as a function of the prototypicality of the case histories, with the least prototypical cases having the lowest reliability.  This research and others  suggested that clinicians did not use diagnostic criteria to make diagnoses.  Clinicians’ diagnoses tended to follow a prototype-matching model rather than a criteria-based model.

DSM3R

DSM3R that was published in 1987 was not structurally different than the DSM3 (it had the axis system, used diagnostic criteria and the mental disorders were organized in a similar way) but it contained new categories.

The political struggles concerning the DSM-III centered around a battle between a psychoanalytic faction of the APA and a biologically-oriented faction. When the DSM-III-R was being created, the focus of controversy shifted. Feminists were concerned with proposals by the DSM-III-R committees for new categories such as premenstrual syndrome and masochistic PD. As a result of the controversy, the DSM-III-R added a new appendix to its classifications called “Proposed diagnostic categories needing further study.” Contained in this appendix were three categories: late luteal phase dysphoric disorder (the new name for premenstrual syndrome), sadistic PD (to balance masochistic PD), and self-defeating PD (the new name for masochistic PD).  

In 1992, WAKEFIELD raised attention the fact that a value judgment is necessary to instantiate any definition of mental disorder.   The same symptoms might be judged as disordered in one context but not in another. Further, as societal and individual values change over time, some conditions that used to be disordered will no longer be considered abnormal (e.g., homosexuality), and others that were not disordered might become problematic (e.g., Internet use). Thus, there can never be a “final” version of the DSM.

To be continued in a following post…

DSM1 עד DSM5 – מעגל הסיווגים: חלק שני

DSM1 עד DSM5 –    מעגל הסיווגים:  חלק שני   

זהו חלק שני של פוסט שפורסם בתאריך 17 ביוני.

Blashfield, R. K., Keeley, J. W., Flanagan, E. H., & Miles, S. R. (2014). The Cycle of Classification: DSM-I Through DSM-5. Annu. Rev. Clin. Psychol, 10, 25-51

Allen Frances, M.D DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes.  https://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes

DSM4

DSM4 פורסם בשנת 1994.  השינוי העיקרי בו היה הוספת קריטריון החשיבות הקלינית בכמעט חצי מהקטגוריות.  קריטריון זה דרש שהסימפטומים יגרמו מצוקה או פגיעה משמעותית מבחינה קלינית בתפקוד החברתי, התעסוקתי או בתחומי תפקוד אחרים.  

DSM4TR

DSM4TR פורסם בשנת 2000.  הקטגוריות הדיאגנוסטיות ומרבית הקריטריונים הספציפים לדיאגנוזה לא השתנו. 

בשנת 2005 פרסם SADLER ספר חשוב ומשפיע בשם VALUES AND PSYCHIATRIC DIAGNOSIS.  סדלר כתב על חמישה ערכים והתפקיד שלהם בסיווגים פסיכיאטרית:  א.  אסתטיקה – כיצד אנשים מעדיפים שהדברים יהיו, במובן של הדרך בה הם "אוהבים" או "מעריכים" אותם.  ב.  אפיסטמולוגיה – בחירות שאנו עושים לגבי הדרך בה אנו רוכשים ידע על סיווגים (למשל, באילו שיטות מחקר אנו מעדיפים להשתמש).  ג.  אתיקה – הערכים המוסריים הבאים לידי ביטוי במערכת הסיווג.  ד.  אונטולוגיה – הטבע הבסיסי של "הדברים", או במקרה של פסיכיאטריה, המהות של הפרעות נפשיות במובן ה(מטא)פיסי.  ה.  פרגמטיקה – עד כמה הסיווג שימושי או ידידותי למשתמש.  (אני לא בטוחה שהייתי קוראת לחמשת הדברים הללו "ערכים").  עד פרסום ספר זה, אנשי מקצוע התעלמו מדברים אלה או התייחסו אליהם כמובן מאליו.  הספר הפך את התפקיד שהשיח הפילוסופי משחק בהתפתחות סיווגי הפרעות הנפש ללגיטימי. 

DSM5

DSM5 פורסם בשנת 2013, אך תהליך הפיתוח שלו החל בשנת 1999.  הטיוטות פורסמו באתר באינטרנט ואיפשרו לאנשים להעיר ולהציע.  המטרה היתה להתאים את מערכת הסיווג לממצאים מתחום הביולוגיה המולקלורית, הפסיכולוגיה הקוגניטיבית,  מדעי המוח והפסיכומטריקה.  הקטגוריות שהוצעו נבחנו באחד עשר מרכזים רפואיים.  ב – DSM5 קיימת עליה בקטגוריות שמכסות טווח רחב של סיבות שבעטיין אנשים עשויים לפנות לפסיכיאטר ("השמנת יתר"; "בעיות הקשורות להריון בלתי רצוי"). 

ב – DSM5 בוטלה מערכת הצירים שהיתה קיימת מאז ה – DSM3.  ה – DSM5 מחולק לשלושה חלקים:

החלק הראשון מתאר את ארגון ה – DSM5. 

החלק השני מתאר את כל ההפרעות.  שינויים בולטים בחלק זה הם ביטול תת הסוגים של סכיזופרניה וביטול תת הסוגים של הפרעה על הספקטרום האוטיסטי.  כמו כן בוטל הפרק שכלל "הפרעות שמאובחנות לראשונה בינקות, בילדות או בגיל ההתבגרות". 

בחלק השלישי מוצגים מדדים ומודלים חדשניים.  בין השאר מוצג בו מודל אלטרנטיבי להפרעות אישיות, שהוא מודל היברידי (מימדי – קטגוריאלי).  בתקופה שקדמה ל – DSM5 התעורר ויכוח האם וכיצד ניתן לשלב מודלים מימדיים של האישיות ב – DSM.  אחד המודלים הללו הוא מודל חמשת התכונות הגדולות – ה – BIG5, עליו כתבתי בעבר.

אנשי מקצוע וכן החברה הפסיכולוגית הבריטית טוענים שאישיות "נורמלית" ו"אבנורמלית" אינן נפרדות זו מזו אלא נמצאות על פני רצף.  ניתן לסווג אישיות "אבנורמלית" על פי אותן חמש תכונות גדולות.  לקראת יצירת  DSM5 הוצע להחליף את כל הקטגוריות של הפרעות אישיות ב – DSM במודלים מימדיים של אישיות.  Blashfield and Keeley טוענים שהופעלו לחצים פוליטים חזקים נגד שינוי זה, ולכן נוצר המודל ההיברידי של קטגוריות (סימפטומים שמאפיינים הפרעות אישיות שונות, ובכך יוצרים "קטיעה" בין מה שנחשב "נורמלי" למה שנחשב ל"אבנורמלי") ושל מימדים.  היו טענות שלאיגוד הפסיכיאטרי האמריקני לא היה אינטרס כלכלי לאמץ מודלים מימדיים של אישיות מכיוון שהזכויות לכלי המדידה של מימדים אלה היו בידי אחרים. 

ביקורות נוספות על ה – DSM5:

הדרך בה הקטגוריות נבנו:  ה – DSM עוסק בעיקר בסימפטומים של הפרעות נפשיות ולא בגורמים להן.  הוא מקבץ את ההפרעות בהתבסס על דפוסים סטטיסטים או קלינים.  דרך זו עלולה לגרום לקיבוץ של אנשים שיש להם אותם סימפטומים אבל שיתכן שהגורמים לסימפטומים אלה שונים לחלוטין ובכך היא מכבידה על התקדמות המחקר.  אך מהי האלטרנטיבה? אני לא בטוחה שיש לנו מספיק ידע שיאפשר לקבץ הפרעות נפשיות לפי הגורמים להן.

אבחון יתר ומדיקליזציה של מצבים נורמלים: יש טענות על כך שההרחבה הניכרת במספר הקטגוריות הדיאגנוסטיות משקפת וגורמת למדיקליזציה גוברת של טבע האדם, ועלולה לגרום לאבחנת יתר של הפרעות נפשיות.  אחד הטוענים זאת הוא ד"ר Allen Frances, מנהל צוות המשימה של ה – DSM4.   הוא טוען שמצבי חיים נורמלים, כמו TEMPER TANTRUMS או אבל טבעי הופכים להפרעות נפשיות ב – DSM5. 

עד כמה מבנה ה – DSM עולה בקנה אחד עם הדרך בה קלינאים מאבחנים בשטח:  במחקרים על הדרך בה קלינאים מנוסים מקבלים החלטות דיאגנוסטיות עולה שהם אינם משתמשים ברשימות קריטריונים כאשר הם מקבלים החלטות דיאגנוסטיות.  במקום זה הם מתאימים/משווים בין  הפציינט החדש לפציינטים שהם ראו קודם תוך שימוש בפרוטוטיפ/אב טיפוס.  ולכן יש טענה שהקריטריונים הדיאגנוסטים ב – DSM   מתאימים יותר למחקר מאשר לעבודה קלינית (אך ראה נקודת ביקורת קודמת...).  מחברי המאמר (Blashfield and Keeley) כותבים שייתכן שעדיף שיהיו ב – DSM  תיאורים פרוטוטיפים. 

תהליך חיבור ה –    :DSMה – DSM5  עורר ביקורת לגבי הדרך הסודית בה תהליך חיבורו התנהל וההשפעה המשחיתה האפשרית של הרווחים הפוטנציאלים של האגודה הפסיכיאטרית האמריקנית ממנו.  החלטות חשובות לגבי קטגוריות של הפרעות נפשיות התקבלו על ידי חבר הנאמנים של האיגוד הפסיכיאטרי האמריקני. 

מחברי המאמר ממליצים שב – DSM הבא תהיה שקיפות גדולה יותר לגבי זכויות ותשלומים שמקבלים אנשים המעורבים ביצירת ה – DSM, ולגבי מימון על ידי חברות תרופות או חברות אחרות שיכולות להיות מושפעות כלכלית מהחלטות לגבי DSM, וכו'.  חברים רבים בצוות הפיתוח של ה – DSM5 היו בעלי קשרים כלכליים לחברות תרופות.