new DSM-V article

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You beat me to it.

I don't even know what to say about the DSM-V anymore. The project has dissolved into a very complicated mess. Even when you try to take it on an issue-by-issue basis there are so many factors that come into play.
 
I can't wait to see what the work groups post on the APA website next month.
 
Where does all this "bible" sh--t come from? Why do articles continue to give this impression. It not a bible of the profession and ive never heard anyone ever reffer to it that way.
 
erg923 said:
Where does all this "bible" sh--t come from? Why do articles continue to give this impression. It not a bible of the pr ofession and ive never heard anyone ever reffer to it that way.
Click to expand...

You mean you don't insist on swearing on a copy of the DSM when testifying in court?
 
Yeah, saw this the other day.

I'm glad its release is being delayed since it sounds like they are trying to do too much too soon, and based off what I know of how it has progressed - there is no way they could have met their original goals.

I've half-jokingly referred to it as the "Bible", and probably have even done so on this board. When I've said that, I have largely been referring to the fact that it is a major driving force that guides a number of attitudes and decision points in the field, and is given far more authority than I think it should be. Just like the bible, there is very little reason to believe it is accurate, but people still have faith that it is and act accordingly. Are depression and anxiety REALLY unrelated disorders that just happen to co-occur on a regular basis? We often treat them as such. Millions and millions of dollars of public money is spent doing research that examines them in that way. Treatment studies are expected to make sure individuals meet diagnostic criteria...the number of researchers integrating a dimensional approach into treatment research are minimal. I imagine it would be very difficult to get funding for because again...the system. I don't think the comparison to the bible is unfair at all...in fact your post kind of forced me to think through it, and I'm now even further convinced it is treated as a bible in this field.

I think the biggest problem is just meeting so many diverse needs. We pretty much know for a fact that many of the foundations on which we have built the DSM model of psychopathology are just flat out wrong. However, our mini-society has been structured around those foundations so the question is when to make the shift.

For example, the literature on taxonomy of MDD seems to converge pretty clearly on the idea that it exists on a continuum. In contrast, I have seen precisely zero support for the magic number of 5 in the current manual. Differentiation from anxiety is a related issue, but for now I'm going to focus strictly on depression. If we want the DSM to accurately reflect how the world works, then obviously we would need to remove that. However, thats hugely impractical. It makes things far more complicated. Its pretty incompatible with our current system of healthcare. So is the job of the DSM to be the "truth" or is it just a framework for operating within the system? At what point do we then decide its time to change the system?

Its a thorny issue, but a critical one. The broader goal of my research program basically consists of re-formulating our entire conceptualization of psychopathology, so its one that is very near to my heart. I think for this to work, research needs to lead the way and we need broad acceptance and implementation of a new diagnostic structure across the spectrum before it makes it into the mainstream. Right now, there is a DEFINITE divide even within sub-facets of the research community, let alone the clinical world. Unfortunately, the research world has its own set of systematic barriers and other problems that prevent that from being easily resolved.

So its a process, and a tough one. I wish I knew what could be done about it.
 
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erg923 said:
Where does all this "bible" sh--t come from? Why do articles continue to give this impression. It not a bible of the profession and ive never heard anyone ever reffer to it that way.
Click to expand...

That book, with its pervasive lack of validity and reliability, across its various iterations, is hardly a "bible" for most clinical psychologists. I think it is used because psychiatry created it, and the insurance companies require it. I have often felt that its high time that psychology came up with its own diagnostic system ... one which is valid and reliable .... well if we could ever agree on anything😀 This of course presupposes that the medical model is even valid 😛 The only good thing about it is that it gives us a common nomenclature.
 
Well actually, some diagnosis in the DSM are very reliable........that certainly doesnt mean they are valid though.
 
I hear when they finally release it, it's going to ship with a copy of Duke Nukem Forever.
 
Thrak said:
I hear when they finally release it, it's going to ship with a copy of Duke Nukem Forever.
Click to expand...

Nice. Well, "Chinese Democracy" finally came out, so I guess anything is possible 😉.
 
Ollie123 said:
Yeah, saw this the other day.

I'm glad its release is being delayed since it sounds like they are trying to do too much too soon, and based off what I know of how it has progressed - there is no way they could have met their original goals.

I've half-jokingly referred to it as the "Bible", and probably have even done so on this board. When I've said that, I have largely been referring to the fact that it is a major driving force that guides a number of attitudes and decision points in the field, and is given far more authority than I think it should be. Just like the bible, there is very little reason to believe it is accurate, but people still have faith that it is and act accordingly. Are depression and anxiety REALLY unrelated disorders that just happen to co-occur on a regular basis? We often treat them as such. Millions and millions of dollars of public money is spent doing research that examines them in that way. Treatment studies are expected to make sure individuals meet diagnostic criteria...the number of researchers integrating a dimensional approach into treatment research are minimal. I imagine it would be very difficult to get funding for because again...the system. I don't think the comparison to the bible is unfair at all...in fact your post kind of forced me to think through it, and I'm now even further convinced it is treated as a bible in this field.

I think the biggest problem is just meeting so many diverse needs. We pretty much know for a fact that many of the foundations on which we have built the DSM model of psychopathology are just flat out wrong. However, our mini-society has been structured around those foundations so the question is when to make the shift.

For example, the literature on taxonomy of MDD seems to converge pretty clearly on the idea that it exists on a continuum. In contrast, I have seen precisely zero support for the magic number of 5 in the current manual. Differentiation from anxiety is a related issue, but for now I'm going to focus strictly on depression. If we want the DSM to accurately reflect how the world works, then obviously we would need to remove that. However, thats hugely impractical. It makes things far more complicated. Its pretty incompatible with our current system of healthcare. So is the job of the DSM to be the "truth" or is it just a framework for operating within the system? At what point do we then decide its time to change the system?

Its a thorny issue, but a critical one. The broader goal of my research program basically consists of re-formulating our entire conceptualization of psychopathology, so its one that is very near to my heart. I think for this to work, research needs to lead the way and we need broad acceptance and implementation of a new diagnostic structure across the spectrum before it makes it into the mainstream. Right now, there is a DEFINITE divide even within sub-facets of the research community, let alone the clinical world. Unfortunately, the research world has its own set of systematic barriers and other problems that prevent that from being easily resolved.

So its a process, and a tough one. I wish I knew what could be done about it.
Click to expand...

👍 Very thoughtful post!
 
JockNerd said:
Interesting read...

http://www.newscientist.com/article/mg20427381.300-psychiatrys-civil-war.html?full=true
Click to expand...

You know I have mixed feelings about this book, because I have seen the goods... and the bads. Obviously people like Szasz and Breggin have contributed immensely to why this book and much of psychiatry is problematic, but without the book, imagine how disorganized much of the field(s) would be. However, on the same token, one could argue that if this book were never put together a better one would have eventually come out.

I agree with the need for a fundamental switch, but its not as easy as some of the other fundamental model swtiches that happen in other sciences (which btw are not that easy to begin with) but in this case we have patients to think about, is it really in the patients best interest to change things entirely? Fact is, the change wouldnt be correct right away, think about how long the DSM has been in development and from what you all are saying its still somewhat rubbish.

My roommate's lab at the NIH has a PI that is helping revise the Autism section for the new DSM, and they seem to believe in this book for that purpose to its end. I am not in a qualified position to say otherwise, nor will I ever be, and I truly don't think many of you are either, even if you have "worked with or done research" for a couple of years, I still dont think that qualifies you to speak on the matter. I do not see why a fundamental switch is necessary, but as the book already does, revisions should be, and maybe even complete reworkings of certain areas.

Its funny to me how in one forum people are worrying about losing insurance coverage, but then in this forum people are talking about doing away with the DSM, I would guess that doing away with the DSM might help in doing away with *some* of the coverage by insurance companies... think about it

disclaimer: I am not supporting one side or the other on this matter, I can just see both sides and think people should consider both sides and the consequences

J
 
Is it true Borderline PD may become Axis I in the new version?
 
While the Psychodynamic Diagnostic Manual is far from perfect, I think it offers an interesting contrast to the current DSM. Anyone who hasn't flipped through one should check it out.

As for the DSM-V....it is an ambitious effort, but I'm not sure "major" changes can be made to something like the DSM. For my own interest, I'd love to see "Emotional Eating" as something more than ED-NOS. I'd also like to see a "Complex PTSD" added. I'm not the biggest fan of Cognitive Disorder-NOS and some of the other "punt" Dx's that seem to pop up on charts pretty frequently. There are more, but I'll leave those for another day.
 
I think it's far easier to criticize a system that is seemingly broken, but our response has also been to offer specific, concrete suggestions on how the update process could be improved for future revisions:

http://psychcentral.com/blog/archives/2009/12/17/dsm-v-suggestions-for-change/

The DSM is a necessary evil and is not going anywhere anytime soon. The key then is to work on how best to make sure the problems we're now seeing don't repeat themselves in the future.

John
 
No, I think more like Emotion Dysregulation Disorder in the Mood Disorders. I've also heard the argument for changing it to Emotion Dysregulation PD if the PD section is kept (which it may not be), but I think that would likely be a stepping stone to moving it to Axis I.
 
I'd hope BPD isn't given either of those labels actually. Borderline is DEFINITELY not my area, but as far as I know while traumatic events are incredibly common they aren't necessary, and their causal role is certainly on much shakier ground than PTSD. I think Emotion Dysregulation is closer, but still an oversimplification.

I'm interested to hear the reasoning for moving it to Axis I. I don't necessarily disagree with that decision. Correct me if I'm wrong, but isn't it difficult to get insurance to cover Axis II dx at times? If so, from a sheerly practical standpoint it makes sense to move it to Axis I, especially given that treatment is far better-established than for most other disorders.

To some extent semantics....to some extent an incredibly critical decision point...this is going to be interesting🙂

I've said it before T4C, but I really do need to get a copy of that manual just to see how it is set up.

DocJohn - I agree wholeheartedly actually, and I'm glad there has been more discussion of changes to the process (from you and many many others).
 
Well the name Borderline has nothing to do with the disorder at all (just an incorrect historical view that it was at the borderline between neurosis and psychosis), so I would definitely approve of Emotion Dysregulation (Personality) Disorder as a step in the right direction. And also, many people who do research BPD do believe (myself included) that emotion dysregulation is in fact at the heart of all of the dysfunctional behaviors in BPD. There may be more to it than that, sure, and more details to be understood in how emotion dysregulation in BPD leads to such high levels of dysfunctional impulsivity and interpersonal difficulties, but many disorders have more to them than the most central thing in the name.

I suspect one reason to move it and other PDs to Axis I is that Axis II is considered "untreatable" by many, including often insurance companies, and thus not covered, as you say. Given that there is a good EBT for BPD, that's a shame if that's happening. Also, Axis II is kind of tainted in some people's minds by its heavily psychodynamic bent, so I suspect for disorders where there is an increasingly non-psychodynamic approach (like BPD), there may be a push to differentiate them from that, and possibly eventually ditch the rest that don't make the transition. Schizotypal PD is already part of the psychotic disorders in the ICD and is genetically linked to schizophrenia, and Avoidant PD is basically the same thing as Generalized Social Phobia. So that's already potentially three that could be no longer Axis II/PDs.
 
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Well if borderline is your area, I'll definitely defer to you on that one. I agree calling it "emotion dysregulation" is a step in the right direction, but I tend to let my perfectionistic tendencies get the better of me on such matters and potentially delay progress😉

Impulsivity was the specific thing I had in mind when I questioned whether emotion dysregulation was an appropriate name. I've always viewed the borderline "prototype" as the combination of emotion dysregulation and impulsivity.

Any recommended articles (theory or empirical) on the notion of emotion dysregulation as the "core" process? Or is it more just a general feel from the literature than a specific proposed model at this point in time? The idea that emotion dysregulation can lead to impulsivity is also fascinating and not something I'd really heard before...so suggestions there would also be appreciated.

If not, no worries, but figured I'd ask since I love these kinds of issues....
 
This sort of thing is still being researched currently, so a lot of it is theory that is supported by current evidence, but not fully fleshed out with research yet. I'd strongly recommend reading work by Marsha Linehan, Kim Gratz and Alex Chapman if you want a better idea of the nature of emotion dysregulation in BPD though. Good stuff!
 
Ollie123 said:
Any recommended articles (theory or empirical) on the notion of emotion dysregulation as the "core" process? Or is it more just a general feel from the literature than a specific proposed model at this point in time? The idea that emotion dysregulation can lead to impulsivity is also fascinating and not something I'd really heard before...so suggestions there would also be appreciated.
Click to expand...

To answer your question Ollie, I recently read an article does a very nice job of summarizing current thinking on the topic. It's very much a theoretical article, building off of previous work to try to explain BPD more fully, but it's still a really interesting read. Furthermore, it ties in both the emotional dysregulation and behavioral dysregulation (what you might call impulsivity) in its explanation of BPD.

Title: Cascades of emotion: The emergence of borderline personality disorder from emotional and behavioral dysregulation.
Review of General Psychology Vol 13(3) (Sep 2009): 219-229
Authors: Selby, Edward A. & Joiner, Thomas E., Jr.

Hope that helps!
 
I understand changing the name, but I'm not sure if I understand changing it to Axis I. Though, yeah, insurance coverage would be good, to me it will lend more arguments to the people who believe PDs do not exist.

And, yes, I attended a lot of the BPD emotion dysregulation presentations at ABCT this year. The theory is pretty solid.
 
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cara susanna said:
I understand changing the name, but I'm not sure if I understand changing it to Axis I. Though, yeah, insurance coverage would be good.

And, yes, BPD is thought to be a disorder of pervasive emotion dysregulation. It's also been found to be linked to deficits in mindfulness, which is interesting.
Click to expand...

Isn't mindfulness training one of the key aspects of DBT?
 
Evidence Based said:
Title: Cascades of emotion: The emergence of borderline personality disorder from emotional and behavioral dysregulation.
Review of General Psychology Vol 13(3) (Sep 2009): 219-229
Authors: Selby, Edward A. & Joiner, Thomas E., Jr.
Click to expand...

Thank you for the reference! I always appreciate when people offer citations, as I really enjoy digging into the research.

I wonder if the move is also tied into insurance reimbursement, as bipolar seems to be the "replacement" Dx that pops up frequently, as services are more likely granted and reimbursed the the Dx. With a move to Axis-I, I think it has a much better chance of being covered. Thoughts?

ps. Ollie....The PDM is an interesting read. I wish I had more time to read it. I bought it when it first came out, but it just sites on my shelf for the moment....about 8' from me right now. :laugh:
 
Bipolar and BPD definitely share some similarities, although I cringe at the thought of someone suffering from BPD just being handed lithium for their symptoms. If BPD moves to Axis I, it becomes "respectable," and of course probably more easily billable. This might also come as a move to distinguish BPD from other PDs. BPD has a good deal of research backing it as a valid diagnostic concept, something which most of the rest of Axis II really lacks. I mean, how would one go about treating Histronic PD? Schizoid PD?
For the sake of those suffering from BPD, I would definitely support a name change and a move to Axis I. A more comprehensive solution, however, would be to garner more research into the rest of Axis II (beyond BPD and perhaps Narcissistic and Anti-social PDs) to establish this diagnoses on firmer footing. Right now, you can hardly blame someone for thinking that a lot of PDs don't actually exist.
 
That is true, PDs in general need more research behind them. BPD is the most well-supported and researched, so it makes sense, but it also kind of implies that a disorder can "graduate" to Axis I, and that PDs are just an auxilary category to shove a disorder into until it is further fleshed out. I don't think that's necessarily a good idea.
 
cara susanna said:
That is true, PDs in general need more research behind them. BPD is the most well-supported and researched, so it makes sense, but it also kind of implies that a disorder can "graduate" to Axis I, and that PDs are just an auxilary category to shove a disorder into until it is further fleshed out. I don't think that's necessarily a good idea.
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Point well taken. Unless we see a complete revamping of Axis II in the DSM V, it wouldn't exactly look good to use Axis II as a holding bin for disorders until we figure out exactly what to do with them. I would certainly be intrigued by a dimensional model of personality disorders as a way to put them on more empirical empirical grounds, although this too has its problems and is a topic for a different time.

As always, we're left saying "Further research must be done."
 
To me it brings up the question of what differentiates Axis I from Axis II. A personality disorder is supposedly a pervasive pattern of rigid and maladaptive behaviors and responses, right? And what about the idea of personality "styles" and "traits"? If BPD becomes Axis I, does that mean we can no longer say someone has BPD traits? What makes a disorder Axis I instead of Axis II, and vice-versa? I thought it was fairly well-defined, but if they take certain PDs and make them Axis I now, it is even more muddled.

If you're going to just suddenly decide that a disorder is Axis I and not II, I think you need to rethink the entire concept of personality disorders.
 
On Axis I disorders:

I have no clue how common this opinion is (I'm guessing not very, as it seemed a bit unusual to me), but my abnormal psych instructor flat out told us that she "didn't believe in PDs" because she didn't like the idea that a person's whole personality could be pathological (she did say she sometimes dx'ed them anyway 😕)... It could be that moving d/o's between axises could be a way to "legitimatize" them to some clinicians and, as previously mentioned, to insurance companies. (This person's area of research? Mindfulness, ironically!)
 
Although pd's are not my area of interest/experience, I have ran into a few problems with them. For example, the majority of inmates in prisons would meet the criteria for an antisocial personality disorder diagnosis. I don't really know how likely this is, which makes me think that APD is not a valid diagnosis, as it stands right now. On the other hand, if APD is valid, does that mean the legal system is biased towards this one disorder? I don't think so. For me, at least, APD should be characterized by lack of emotion, empathy, etc. Although, I guess that brings up the whole APD vs. psychopathy debate. Hopefully the DSM V will make adjustments to this.
 
I know a few people who don't believe PDs exist. I argue with them a lot. 😉

Psych: I like Millon's idea of a Sadistic Personality as well as Antisocial.
 
cara susanna said:
Psych: I like Millon's idea of a Sadistic Personality as well as Antisocial.
Click to expand...

I just looked into that---very interesting. In my mind, I guess I picture APD as a blurring of sadistic pd and psychopathy, with a major focus on lack of empathy (my area of research). I guess we will have to wait a little longer before an update on how to reconcile sociopathy, psychopathy, apd, sadism, etc. It makes research very difficult when everyone has different definitions for one disorder
 
cara susanna said:
To me it brings up the question of what differentiates Axis I from Axis II. A personality disorder is supposedly a pervasive pattern of rigid and maladaptive behaviors and responses, right? And what about the idea of personality "styles" and "traits"? If BPD becomes Axis I, does that mean we can no longer say someone has BPD traits? What makes a disorder Axis I instead of Axis II, and vice-versa? I thought it was fairly well-defined, but if they take certain PDs and make them Axis I now, it is even more muddled.

If you're going to just suddenly decide that a disorder is Axis I and not II, I think you need to rethink the entire concept of personality disorders.
Click to expand...

This, for me, argues in favor of the dimensional perspective when looking at personality organization. I think most (maybe all) individuals have personalities organized around certain defensive structures. So you have very "normal" people who have narcissistic, paranoid, or hysterical features, as well as those for whom those features are so numerous, deeply entrenched and rigid that they severely limit overall life functioning (Axis II level personality disorders). The problem for me in the DSM's treatment is that it is categorical, thus limiting the dimensionality of personality functioning/impairment. While this makes sense if you think of the DSM as a handbook of "disorders" it's less clinically useful because it artificially dichotomizes personality structure.
 
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