The 5th

[Fastball32]

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Starting a new thread on topics regarding the next DSM should be interesting.
New updates will be added on a regular basis.

I love intellectual stimulation so comments are encouraged.

#1. The DSM will officially lose the roman numeral system and adopt the arabic system.
Thus, it'll be DSM-5, and not DSM-V.

Rationale:
DSM-IV debuted in 1994, before the internet was mainstream. Now that knowledge is available like no other time in history, DSM searches will be more accurate using "5" instead of "V".

reference (scroll to the last FAQ on the page): http://www.dsm5.org/about/Pages/faq.aspx

 

[billypilgrim37]

More than just being easier in searches, the committee also wants updates to be easier than waiting every 15-20 years. The head of the DSM committee has made statements about this being "DSM5.0," which hopes that "DSM5.1", etc. could be much more minor updates to reflect relatively up-to-date neuroscience research. Not sure if the APA really sees it that way. They're going to want to sell books for awhile.

 

[Fastball32]

Just like Apple's Operating System - 10.5 (Leopard), 10.6 (Snow Leopard), 10.7 (Lion), etc.; the DSM will adopt 5.1, 5.2, etc.

Our last update DSM-IV-TR is 12 years old...

DSM 5.x with more rapid updates will encourage more research and better guide our treatment. This should be good.

 

[tryp]

How are people feeling about the revisions to the personality disorders?

I have been following Borderline Personality Disorder the most closely because that's what I'm interested in, and so far I think the changes are favourable. Most of the symptoms that were in the last version are still included, but they have been grouped and classified in a way that I think is more clear, and I like that they have included more full descriptions of each characteristic within the criteria.

I also think it's good that they have included self-harm under impulsivity rather than as its own criterion because I think that there might have been an issue before with anyone who self-harms being slotted into BPD automatically.

 

[nitemagi]

How are people feeling about the revisions to the personality disorders?

I have been following Borderline Personality Disorder the most closely because that's what I'm interested in, and so far I think the changes are favourable. Most of the symptoms that were in the last version are still included, but they have been grouped and classified in a way that I think is more clear, and I like that they have included more full descriptions of each characteristic within the criteria.

I also think it's good that they have included self-harm under impulsivity rather than as its own criterion because I think that there might have been an issue before with anyone who self-harms being slotted into BPD automatically.

Much of the critiques on the personality disorders is that it makes diagnosing excessively complex. I believe the retort to that is that personalities, in truth, ARE very complex. Our diagnostic formulations should really reflect that.

 

[Fastball32]

How are people feeling about the revisions to the personality disorders?
.

The Personality Disorders is probably the biggest change that is anticipated with the next DSM.
Up front, we will go from 10 Personality Disorders to 5: Schizotypal, Borderline, Antisocial, OCPD, and Avoidant.
Bye bye to Narcissism, Histrionic, Schizoid, Paranoid, and Dependent.

The rationale is quite long, but one of the reasons is based on John Oldham's older study that shows a majority of people with Personality Disorders will meet criteria for more than one.
The reasons to keep the five remaining are: clinical usefulness, diagnostic validity, and prevalence (can't think of the last one off the top of my head).

One of the goals is to use Personality Dimensions, so we can describe personality in individuals even without a disorder. The dimensions are loosely related on the Big 5 theory of personality (Openness, conscientiousness, agreeableness, extroversion, and neuroticism). So once we diagnose the Disorder, we will have to rate how close a fit they are to the actual disorder, and also rate individual traits. These traits are where Histrionic, Schizoid, depedent, narcissism traits will factor in. Seems like it may be quite a bit of paperwork, especially in contrast to how we often deal with personality now, which is to defer.

 

[cara susanna]

There is a lot of valid criticism against the dimensional approach to personality. Many people on the DSM committee for personality disorders are upset by the decision and don't think it is really backed by science.

I'm very unhappy about it myself, especially because I don't really like the Big Five. Also, I think this won't give us a good clinical picture of what the person is like if they actually do have personality pathology.

 

[Vasa Lisa]

I wasn't sure what thread to post this under...

Did anyone read this in the Washington Post?
http://www.washingtonpost.com/opini...good/2012/04/27/gIQAqy0WlT_story.html?hpid=z4

I know there are lots of articles pro and con about the new revision. What struck me about this one was the anecdote about the harm that comes when a dx becomes a definition.

I see clients who are older who at one time met criteria for various disorders, but through tx, maturity, time, loving and being loved, they don't meet the criteria anymore, but the dx follows their permanent health record and can keep them from being able to purchase private individual health insurance.

Thoughts?

 

[aphenomenon]

I wasn't sure what thread to post this under...

Did anyone read this in the Washington Post?
http://www.washingtonpost.com/opini...good/2012/04/27/gIQAqy0WlT_story.html?hpid=z4

I know there are lots of articles pro and con about the new revision. What struck me about this one was the anecdote about the harm that comes when a dx becomes a definition.

I see clients who are older who at one time met criteria for various disorders, but through tx, maturity, time, loving and being loved, they don't meet the criteria anymore, but the dx follows their permanent health record and can keep them from being able to purchase private individual health insurance.

Thoughts?

While i agree with general sentiments of overmedicalization and the sometimes poor effects of labeling and diagnosis, I found the article poorly written in terms of its arguments, examples, substantiation, and intent.

 

[whopper]

From what I've been seeing of the DSM V so far, I'm not exactly jumping for joy thinking it's a vast improvement.

If your read the DSM-II and compare it to the DSM-III there is a vast improvement. The DSM II went from a format where it was about a bunch of stuffy doctors in a room voting on what to diagnose based on personal opinions, and III shifted more on data from actual studies. DSM IV went on to clean up and push forward what was established in III.

Now the V does do that more but not in a manner where I'm finding it to be significant. Some areas I wished they really cleared up are the diagnosis of ADHD that I still find to be complete bull and too open for interpretation and thank God I was introduced to the TOVA test from a psychology colleague (Do you have problems in wanting to do your homework? Were you ever in a clas and just wanted to walk out? WHO THE FRACK HASN'T EVER HAD THAT PROBLEM? DOES THAT MEAN WE ALL HAVE ADHD?!?!?!)

Another area is the issue with borderline PD. Yes I do think some of the issues with it are being advanced in the V, but I am so frustrated with how the profession as a whole misdiagnoses people with borderline PD as bipolar DO, and quite a bit of it has to do with billing. I really believe they need to tackle this issue head-on. Someone self-mutilating and being para-suicidal for years is serious. Because it's a PD, it's suddenly become a non-issue in terms of billing and people with serious borderline PD as a result are often kicked to the curb. The disorder can be quite ruinous to a person's life and this is an issue where we as a profession ought to be proactive in getting people with borderline PD treatment, if not from ourselves then at least from someone trained to do so while not misdiagnosing this truly troublesome problem.

Perhaps the problem isn't with the DSM, but with the way insurance companies and managed care have arbitrarily decided what gets billed and what doesn't. According to head of the mental health board in a county I work in, the gov will give people payments/assistance for antisocial PD, but will not for borderline PD, even when the borderline PD is quite severe. A woman raped multiple times as a child and having problems over it as an adult in the form of borderline PD can get no government help, but the rapist who did this to her can if he has ASPD. Explain to me the logic in that.

And perhaps I'm not reading enough of it to see a possible vast improvement that I'm not aware of in the V.

 

[billypilgrim37]

Because it's a PD, it's suddenly become a non-issue in terms of billing and people with serious borderline PD as a result are often kicked to the curb. The disorder can be quite ruinous to a person's life and this is an issue where we as a profession ought to be proactive in getting people with borderline PD treatment, if not from ourselves then at least from someone trained to do so while not misdiagnosing this truly troublesome problem.

You know, come to think of it, I don't believe I've ever had a patient with BPD who I didn't think also had another Axis I diagnosis too. I imagine between comorbid dep/mood nos and ptsd/anx nos, there aren't a ton of folks who wouldn't qualify for an axis I as well. Even the cutters probably qualify for an ICD NOS diagnosis. Your point is clear and well taken, but practically the problem seems to be more the misapplication of the bipolar label which then compels unhelpful and harmful pharmacologic treatment.

 

[Ibid]

I wasn't sure what thread to post this under...

Did anyone read this in the Washington Post?
http://www.washingtonpost.com/opini...good/2012/04/27/gIQAqy0WlT_story.html?hpid=z4

I know there are lots of articles pro and con about the new revision. What struck me about this one was the anecdote about the harm that comes when a dx becomes a definition.

I see clients who are older who at one time met criteria for various disorders, but through tx, maturity, time, loving and being loved, they don't meet the criteria anymore, but the dx follows their permanent health record and can keep them from being able to purchase private individual health insurance.

Thoughts?

Dear Jane Doe,

Due to a recent change by the DSM committee it is with great pleasure that I can write to you and tell you that you are no longer sick!!

We hope you enjoy your new life free from disease and all associated stigma.

Yours sincerely,
Dr. Bonkers

ps You can stop taking the tablets as well and if you attend a support group you can stop going to that as well now.

 

[F0nzie]

Dear Jane Doe,

Due to a recent change by the DSM committee it is with great pleasure that I can write to you and tell you that you are no longer sick!!

We hope you enjoy your new life free from disease and all associated stigma.

Yours sincerely,
Dr. Bonkers

ps You can stop taking the tablets as well and if you attend a support group you can stop going to that as well now.

The lady in the article clearly has FSI (fear/sadness/insomnia). It's too bad employers aren't looking for these characteristics to satisfy their bottom line.

 

[whopper]

Even the cutters probably qualify for an ICD NOS diagnosis. Your point is clear and well taken, but practically the problem seems to be more the misapplication of the bipolar label which then compels unhelpful and harmful pharmacologic treatment.

You kinda answered why I disagree.

If someone cuts themself due to borderline PD, I'm supposed to put that diagnosis down, not an NOS when I believe the problem is from borderline PD. In effect, because of the diagnostic system's poor interface with the billing system, it encouraged doctors to put the wrong diagnosis down.

Someone self-mutilating due to borderline PD and with no other disorder only has borderline PD, and in order to avoid insurance fraud, I'm supposed to put down the diagnosis I believe the patient truly has.

Yes, with several borderlines, there could be comorbid depression, or bipolar disorder, or an anxiety disorder, but of course there are people with just borderline PD and if that's the case, I'm supposed to simply use that as a diagnosis. Yes I do understand and acknowledge that a borderline PD person could truly have a comorbid disorder, but if someone is self-mutilating due to borderline PD that doesn't somehow magically make it mood DO NOS, psychosis NOS, anxiety DO NOS, what have you, it's still borderline PD.

A way to fix this situation using the DSM-V is if the billing wasn't based specifically on the diagnosis but on the severity spectrum they're adding. Severe borderlines IMHO deserve just as much coverage as any Axis I disorder.

The reality is doctors are intentionally misdiagnosing in order to get patients services and I've yet to see anyone nab a doctor for committing insurance fraud. Shouldn't this be fixed when we all know that's what's really going on instead of continuing the charade?

 

[Bartelby]

I wasn't sure what thread to post this under...

Did anyone read this in the Washington Post?
http://www.washingtonpost.com/opini...good/2012/04/27/gIQAqy0WlT_story.html?hpid=z4

I know there are lots of articles pro and con about the new revision. What struck me about this one was the anecdote about the harm that comes when a dx becomes a definition.

These stories confuse me. It doesn't match at all with my experience. This leads me to think either...

(1) The psychiatrists I have worked with rock; they understand the difference in "I'm stressed out because I have to take care of my kids" and "I'm floridly and psychotically manic; I am working on a project that will feed all of Sudan, that's why I haven't slept for a couple weeks." Not only that, they try to minimize polypharmacy and encourage lifestyle and psychotherapeutic interventions.

or...

(2) These articles are presenting a one-sided and fundamentally dishonest perspective on the situation. "Oh, this poor lady was just mildly stressed about her kids and these evil psychiatrists shoehorned her into a bipolar diagnosis, put her on multiple harsh pills that permanently devastated her health, and then spread the word so her friends and husband left her alone and shivering in a ditch." How did she really present? Was it that simple? Did the psychiatrist's actions really cause her to lose her health, wealth, and friends when she otherwise would have had a relatively problem-free life?

So what's the deal? Am I just seeing unusually good psychiatrists because I have mostly worked at an academic tertiary care center? These horror stories just seem weird to me, and far removed from my experience.

 

[whopper]

The psychiatrists I have worked with rock

Throughout my career, I've consistently seen doctors across the board do poor care. With regards to psychiatry, it's easy to misdiagnose someone as bipolar disordered for billing purposes.

Since I've joined the university, it's been one of the first times in my life where the standard of care among the doctors as a whole here has been higher. Doctors here wont' write bipolar disorder unless they are confident the person actually has it or they'll mention they have some reservations about it and documented why they put their diagnosis. Part of my current job is to work at a private psychiatric facility (the Lindner Center) 6 weeks a year and there too there is higher than standard care. You might be in a similar situation where perhaps where you're at is a cut above so you're not seeing this problem as much.

 

[toothless rufus]

That story is ridiculous and it sounds made up.

Stress--->palpitations---->Dx Bipolar--->invol admit--->unncessessary meds--->get on disability--->become a social pariah--->lose friends and wealth--->🙄

"Psychiatric diagnosis is unregulated, so the doctor who met briefly with the aforementioned patient wasn't required to spend much time understanding what caused her heart to race or to seek another doctor's opinion. If he had, the patient would have realized that her bipolar diagnosis wasn't necessary or appropriate. Neither on her ER trip nor in later visits to therapists did anyone explain how sleep deprivation impairs the body's ability to handle pressure."

Oh come on!

 

[whopper]

During my PGY-2 here was a true story.

Chinese guy who didn't speak English was having chest pain and fell to the ground grabbing his chest. 9-1-1 was called and they brought him to the ER. Despite that in NJ, there's a law saying that if English is not the person's native language an interpreter must be offered unless the doctor speaks the person's native language, the ER doc didn't use one, and no, the ER doc didn't speak Chinese.

The ER doctor labelled the guy as psychotic without using an interpreter and shuffled him to the psychiatric emergency center.

In that center, the psychiatrist there too did not use a translator. They put him in inpatient and wrote down that he was so disorganized he didn't speak appropriately.

Now this poor guy comes to me, and I use an interpreter, and he thanks me for stopping his chest pain, he's coherent, and I don't know WTF he's talking about. So I tell him he's on a psychiatric unit and he tells me he's not mentally ill. I go through the notes and no one bothered to use an interpreter. We do the collateral--there's no history of mental illness (the guy's in his 40s), he works full-time as a chef, and while the guy was on the unit for 3 days there's no signs or symptoms of psychosis.

Chest pain --> guy's misdiagnosed as psychotic ---> ends up on a psychiatric unit.

No this was not daily stuff, but I saw something this bad happen about once every few months. When it came to people being diagnosed as bipolar disordered for typical things (e.g. fighting with the wife) I saw that daily in residency.

To add insult to injury, the patient didn't have insurance, the IM consultant refused to show up and check this guy out (saying it was the ER doc's responsibility to have gotten this so why should he do an evaluation-yes this IM doc IMHO was a brat), so the psychiatry attending refused to discharge him until the IM guy showed up to give him a clean bill of health for a discharge citing that EMTALA demanded that this patient get a CV evaluation and to not do so would not be the standard of care--keeping him there for 3 days and running up his bill.

In reference to that article, I find some of it's finger-pointing to psychiatry as valid, though I also find the tone that a diagnosis including "nicotine dependence disorder" can cost anyone their health insurance, job, custody of their children, or right to make their own medical and legal decisions...
That's a load of crock. A judge will be smart enough to not take someone's rights away if they smoke, and if the judge did that, it's the judge's idiocy, not psychiatry's.
That's ridiculous.

 

[toothless rufus]

Yikes! Poor guy! He should not have had to pay for that psych admit.

 

[siked]

Is anyone else super excited that the five dimensions to personality form a really neat new pneumonic (OCEAN)???

 

[Vasa Lisa]

While i agree with general sentiments of overmedicalization and the sometimes poor effects of labeling and diagnosis, I found the article poorly written in terms of its arguments, examples, substantiation, and intent.

Well it was an op/ed piece - so it isn't written for a peer reviewed journal. I tend to take those types of writings as launching points for thinking and wondering about things.

Another area is the issue with borderline PD. Yes I do think some of the issues with it are being advanced in the V, but I am so frustrated with how the profession as a whole misdiagnoses people with borderline PD as bipolar DO, and quite a bit of it has to do with billing. I really believe they need to tackle this issue head-on. Someone self-mutilating and being para-suicidal for years is serious. Because it's a PD, it's suddenly become a non-issue in terms of billing and people with serious borderline PD as a result are often kicked to the curb. The disorder can be quite ruinous to a person's life and this is an issue where we as a profession ought to be proactive in getting people with borderline PD treatment, if not from ourselves then at least from someone trained to do so while not misdiagnosing this truly troublesome problem.

Yes! whopper! this is one of my areas of clinical interest and focus. Treating BPD is slow work that requires patience, a team, individual tx and group tx, and people do get better. And ideally the medical aspect is monitored and rx support offered in the early stages of tx. YET - I get clients who are on an enormous quantity of medication which may have been helpful at some point in the past - but as the clients gain skills through DBT and other skills based interventions - their need for rx support diminishes. I am not against medication. I have clients who could never have started talk therapy w/o it. And what I find tragic is as people resolve their trauma, improve their interpersonal relationships, mature and improve, we still have a tendency as a profession to "label" cts by their dx. Someone here recommended Vailliant's article "The beginning of wisdom is never calling a patient a borderline." And while dated in some aspects - the core message is still helpful for those of us who do this slow work of seeing clients week in and week out in individual sessions.

Your point is clear and well taken, but practically the problem seems to be more the misapplication of the bipolar label which then compels unhelpful and harmful pharmacologic treatment.

And absolutely this is something that I see in my clients and as a therapist it makes me really appreciate the psychiatrists who take the time to work with my clients by adjusting and weaning and making changes. Because there is such a shortage of psychiatrists - unfortunately many of my clients are taking drugs prescribed by their PCP. Don't get me started...

Bartelby - Lucky you! I too have psychiatrists in my area that are incredibly talented and discerning. And the wait to see one is months and months...

Part of the reason this op/ed captured my attention is that in my current role as a therapist - my interventions and tx come in after all the dx and rx process is completed and I am left with the week by week relationship and skill building of seeing someone over long periods of time. The longer I see someone in individual tx, the less they look like anything in the DSM.

I don't post on this part of the forum much - but I do appreciate the variety of responses and the willingness to have a dialog.

Thanks to all who responded.