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Wednesday 14 November 2012

The DSM-5: The New, The Revised, The Opportunities For Pharma


The DSM-5: The New, The Revised, The Opportunities For Pharma

By Becky Jungbauer | February 10th 2010

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If the folks behind the Diagnostic and Statistical Manual of Mental Disorders (DSM) were crafty, they would have latched on to the upcoming movie, "The Crazies," for some free publicity.1 Although that's probably not quite the image they want to convey, so maybe it was a shrewd non-move after all. Well played, American Psychiatric Association.

For those not in the know, the DSM is the "Bible" for physicians, researchers and insurance companies. The manual "contains descriptions, symptoms and other criteria for diagnosing mental disorders," according to the APA. "These criteria for diagnosis provide a common language among clinicians ... to ensure that a diagnosis is both accurate and consistent; for example, that a diagnosis of schizophrenia is consistent from one clinician to another, and means the same thing to both of these clinicians, whether they reside in the U.S. or other international settings." 

The DSM can also be used by researchers and by insurance companies (for coverage decisions). A common misconception is that the DSM makes treatment recommendations - it doesn't. It aids physicians in arriving at a diagnosis, which will determine a treatment plan, but makes no recommendations on what that plan should be.

The manual has been revised occasionally, since its inception in 1952, to update "criteria for diagnoses that not only reflect new advances in the science and conceptualization of mental disorders, but also reflect the needs of our patients." The new draft out now will become the DSM-V (roman numeral 5, not the letter V).2

So what's new in the draft?

A few things are called out by the APA as being of particular interest - new research on post-traumatic stress disorder, concerns about the diagnosis of gender identity disorder, possible inclusion of non-substance addictions (gambling and Internet), how to better predict a patient's risk of suicide, clarification between bipolar and unipolar, and the possible inclusion of a "risk" syndrome, where clinicians could classify someone at risk of developing a psychosis (much like cholesterol or blood sugar levels are used in heart disease and diabetes).

The idea isn't to further dissect and narrow the disease categories, but rather to "'capture more central themes' about what defines a disorder," the DSM-V task force chairman told the WSJ.

I've taken a step-by-step look at the various changes in the draft, and have highlighted them below for your reading pleasure:

Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence

This will be a biggie. Among the proposed changes are a new disorder, potentially labeled temper dysregulation with dysphoria (though other diagnostic labels, including severe mood dysregulation, are being considered); and a callous/unemotional specifier for conduct disorder. The task force is treading very carefully here, as this could be a minefield. They're also thinking about moving Asperger's into the autistic spectrum.

Delirium, Dementia, Amnestic and Other Cognitive Disorders

They want to divide the category into three "broad syndromes: Delirium, Major Neurocognitive Disorder, and Minor Neurocognitive Disorder." This group also wants to categorize behavioral disturbances, particularly the syndromes of psychosis and depression, associated with Neurocognitive Disorders, and select specific domains as well as measures of severity of cognitive functional impairment.

Mental Disorders Due to a General Medical Condition Not Elsewhere Classified

The only change here is that they'd like to replace "Catatonic Disorder due to..." with a catatonia specifier.

Substance-Related Disorders

This is another one that I think will get a lot of attention, from the media, physicians, patients and especially pharmaceutical companies. First, they want to include both substance use disorders and non-substance addictions. They also want to re-title the category "Addiction and Related Disorders," to get away from the substance part of the definition, because they want to include gambling addiction (currently listed under Impulse-Control Disorders Not Elsewhere Classified) and other addictions like Internet here, as data accumulate. The inclusions and revisions are numerous, so I'll let you read them yourself instead of listing them here.

Schizophrenia and Other Psychotic Disorders

The most interesting change here is the proposal for a psychosis risk syndrome, and whether it should be included in the main manual or in an Appendix for Further Research. The rationale for this is that "young people at risk for later manifestation of a psychotic disorder can be identified. It has been established in follow-back studies that early signs and symptoms of schizophrenia, for example, are present years before diagnosis is established." The potential benefit to including this syndrome, the task force says, is that "psychotic illness is most effectively treated early in the course, raising the potential that early intervention may have long lasting benefit that is not achievable with later therapeutic intervention."

In my personal opinion (and I'm not a psychiatrist, so I'm not speaking for the APA or anyone else), I think this could be one of the most important changes in the DSM. Clearly, as the task force says, you have to consider critical issues like sensitivity and specificity of diagnostic tests, positive and negative predictive power, evidence for effective intervention, and issues related to stigma and potential harm of excessive treatment. But think about the possibilities to benefit so many people - not just the patients, but the patients' families and those who come in contact with the patient. A great analogy is cholesterol levels for heart disease, or even blood sugar levels for diabetes - if you can work on keeping these in check, you can prevent or delay possible negative outcomes. Of course, clogged arteries aren't the same as a neurochemical imbalance, but the idea is there. And this is taking things to extremes, but what if you can predict that someone will have a severe psychotic disorder and treat that - could you possibly stave off any future repercussions like crimes?

This would have to be rigorous and well-researched so it doesn't turn into the next big thing, like every kid who has a temper tantrum has ADHD or every person who is sad once in a while gets Prozac.

Mood Disorders

There are a number of revisions here, mainly about moving things around. Two issues of note - one, the task force wants to include an anxiety dimension across all mood disorder categories as well as a suicide assessment dimension. These would be akin to a co-morbid diagnosis (e.g. depression AND anxiety), but would be more integrated (e.g. depression with 3 of 4 anxiety symptoms). The other issue is that of a new diagnosis for mixed anxiety depression, in which a patient has three or four of the symptoms of major depression which are accompanied by anxious distress.

Anxiety Disorders

This category has all sorts of things happening - revisions, inclusions, movements, etc. Two new proposed disorders are hoarding (not sure about whether to include this in the main manual or the appendix) and skin picking (likely to be placed in the Appendix). Another proposed new disorder was one I had to click on because I had no idea what it meant: Olfactory Reference Syndrome -
a "preoccupation with the belief that one emits a foul or offensive body odor, which is not perceived by others." I think the opposite is true for most high school and college-aged males; they smell and it is definitely perceived by others but they don't know it. (Or care.) The task force also wants to revise how a mental disorder is defined (see here).

Somatoform Disorders

These are generally comprised of psychological disorders that manifest in physical symptoms. The task force wants to rename the category Somatic Symptom Disorders to better clarify that.

Factitious Disorders

They want to get rid of this category and move factitious disorders into Somatic Symptoms. Factitious disorders are when a person acts as if he or she has an illness by deliberately producing, feigning, or exaggerating symptoms (you may have heard of Munchausen's).

Dissociative Disorders

The task force wants to move a few of these into other categories and leave the rest alone for the most part.

Sexual and Gender Identity Disorders

This will be a flashpoint for a lot of people. New disorders for proposed inclusion are hypersexual disorder (what you might think of colloquially as sex fiends), paraphilic coercive disorder (urges focused on coercive sex), sexual interest/arousal disorder in women and in men, and a penetration pain disorder. A point of controversy will be the Gender Identity Disorders, which the task force would like to rename Gender Incongruence. APA says the "
diagnosis of Gender Identity Disorder has created concerns among members of the gay/lesian/bisexual/transgender community, questioning whether the condition is a mental disorder, a physical disorder or a normal variation of human behavior. While much of the concern has centered around treatment, which DSM does not address, the APA will still address issues of diagnosis."

Eating Disorders

The task force wants to rename this the Eating and Feeding Disorders category to reflect inclusion of feeding disorders. Also, they want binge eating disorder be recognized as a free-standing diagnosis apart from the Appendix.

Sleep Disorders

The task force wants greater inclusion of disorders not listed in the mental disorder section of the International Classification of Diseases, as a way to "educate non-expert sleep clinicians (such as psychiatrists and general medical physicians) about sleep disorders that have mental as well as medical/neurological aspects." There are some new inclusions, like Restless Legs Syndrome, that will lend credibility to RLS patients and treatments. Various apneas will also get their own diagnosis, versus being categorized under Breathing Related Sleep Disorders.

Impulse-Control Disorders Not Elsewhere Classified

The task force wants to move pathological gambling to Substance-Related Disorders (to be renamed Addiction and Related Disorders).

Adjustment Disorders

This category would be rendered moot, as they want to group it with other Trauma and Stress-Related Disorders.

Personality and Personality Disorders

The task force wants to overhaul this category - they want "a major reconceptualization of personality psychopathology with core impairments in personality functioning, pathological personality traits, and prominent pathological personality types." For more on this, see the specific section site.

Other Clinical Conditions that May Be a Focus of Clinical Attention

Finally we come to the last category. This diagnostic category includes "conditions related to psychosocial and environmental problems, such as whether a patient is having housing or economic problems or problems with his/her primary support group. In addition, this category contains a listing of movement disorders related to medication use. The work groups are still discussing whether DSM-5 will contain any revisions to these conditions and diagnoses." In fact, all subtypes in this category are recommended to not be included in the DSM-V, with the exception of "Psychological Factors Affecting ... [Medical Condition]."

What's next?

Anyone can comment on the draft until April 20, 2010, after which the draft is put into the real world to see how it holds up in the field. The final version will be published in 2013.

1 Yes, that's sadly an actual movie - see the IMDb site for more. Who vetted that title?
2 To read the draft, peruse FAQs, and learn more about the DSM-V draft, visit this site. They ask for feedback from everyone, not just physicians. You can click on the various categories as I've highlighted above and find out what's proposed to be included, dropped, revised, etc and why. It's actually quite well done, in my opinion.

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