Part I of this series described the process underway to reconstruct the American Psychiatric Association's "Bible," the Diagnostic and Statistical Manual of Mental Disorders (DSM), creating a 5th edition after more than 20 years of DSM-IV. Time for a new model.
The DSM is a hefty tome that specifies 283 mental illnesses, categorized by disorders, including mood, anxiety, eating, sleep, personality, impulse control, adjustment, substance-related, schizophrenia and other psychoses, delirium and dementia, developmental impairments and other diverse conditions.
In Part I of this series, I described how the APA is trying to ensure public transparency, continuous input and ongoing improvements into the drafting of the DSM-5. In this second part, I will cover some of the actual changes in how diagnoses will be made for the DSM-5. In theory, the DSM-5's new and revised diagnostic conditions will reflect the additional scientific information gathered since the last edition, as well as efforts to better cluster and recognize the varied levels of severity of conditions. It will also provide measures for patients, families and doctors to determine if treatment is working. Let's look at some examples.
I will start with substance abuse and addictive disorders, since they are ubiquitous throughout the world -- and as controversial as they are universal. The current draft of DSM-5 proposes that "substance use disorder" replace what we now think of as abuse (seen by behaviors) and dependence (evidenced by withdrawal when the body is denied its drug). Each intoxicant would have its own section, such as alcohol use or inhalant use disorder.
The website identifies the primary reason for this revision as the view that the term "dependence" is misleading: We are urged to not confuse the fact that tolerance and withdrawal are normal responses to some prescribed (read: medically necessary) medications that affect the central nervous system, and thus these physical states should not be seen as an illness. A substance disorder, instead, is a distinct syndrome that includes compulsive drug-seeking behavior, loss of control, craving and marked decrements in social and occupational functioning. Maybe we can reduce stigma with this revision? A good question that time will answer.
But the addiction soup gets thicker when it comes to wondering what, indeed, is an addiction? Is gambling (yes, probably)? Is sex? How about the Internet (without porn)? The votes are not in.
Another critical -- and very controversial -- diagnostic grouping is autism spectrum disorders. Is there an epidemic going on? You would think so, if you listen to the news. The workgroup's recommendation for a new category of autism spectrum disorders reflects its view that autism and Asperger's syndrome (think Dustin Hoffman and "The Rain Man") are a continuum from mild to severe. Many families and advocacy groups are a bit agitated about ending the distinction, which would have effects (likely good and bad) on policy, clinical programs and funding.
In the world of developmental disabilities, the DSM revisionists want to do some wordsmithing on intellectual developmental disorders. "Mental retardation," the experts urge, should be changed to "intellectual developmental disorders" (which would bring the DSM in line with the International Classification of Diseases proposal for its 11th edition -- see Part I for insight into the international scene). But importantly, and realistically, severity of an intellectual disability would not be based only on IQ but by impairment in adaptive functioning as well. That is really overdue.
Another critical cluster of disorders is called "Schizophrenia Spectrum and Other Psychotic Disorders." These are serious and often persistent mental illnesses where a person has profound impairments in being able to appreciate the reality about him or her and diminished functioning in education, work and social relations. The revisions for these conditions, which affect about 1 percent of the population but are among the most costly in terms of loss of quality of life and social cost, are less controversial but allow for an extensive assessment of severity that includes hallucinations, delusions, disorganized thinking and behavior, loss of mental capacity (cognitive impairment) and diminution of feelings, expression and even the ability to act (called avolition, or loss of the ability to start an action). This detailed assessment is a very good idea but is raising questions about the paperwork burden of completing severity measurement scales.
Premenstrual dysphoric disorder (PDD) is a serious mood problem in women that occurs during the premenstrual period. It will appear in the appendix to the main body of the DSM-5 text. The evidence is that this is distinct from premenstrual syndrome (PMS). The addition of this condition could help promote its recognition and promote more research (and better treatment) on this common and disturbing condition. Is this pathologizing monthly lunar-menstrual mood swings, some wonder?
Another debated condition is what is called mild neurocognitive disorder. The aim of this brand new disorder is to identify people at risk for developing dementia, including both Alzheimer's disease and vascular dementia (caused by loss of blood supply to a region of the brain). Symptoms include memory and language loss as well as attentional and reasoning impairments. Do you want to know if you have dementia?
There is a lot more -- including eating disorders, personality disorders (a huge and evocative topic since we all have personalities), and traumatic stress disorders (all the more critical in light of our soldiers, domestic violence, sexual abuse and disaster victims). You can see all of this, and more, on the DSM-5 website. The design of each section on a disorder is very well done, since there are tabs for the proposed revision, the rationale for the revision, severity scales and the current DSM-IV to compare to.
Perhaps one of the most important changes in the DSM is called dimensional assessments (noted above in the discussion of schizophrenic disorders). DSM-IV has had the problem of fitting neatly into the complexity of human symptoms: People with schizophrenia have problems with depression, anxiety even insomnia. There has been, to date, no means to account for these problems, their severity -- and, perhaps most importantly -- to determine if a person is improving in treatment. Dimensional assessments will enable clinicians to record the presence of a variety of problems as well as their severity (very severe, severe, moderate and mild) and thereby be able to track how a person is doing over time and in response to different treatments. This is as needed as it is complicated and demanding.
No wonder the APA constructed 13 work groups, more than 160 people, to revise the DSM -- even before it has to go through the gauntlet of its internal committees, councils and the APA Board of Trustees. Some will say, have said, a fool's errand. After all, how many angels can dance on the head of a pin? I say, however, medicine is a science. Psychiatry is a branch of medicine, a huge limb, in fact, in need of continuous pruning, watering and shaping. Science is not perfect. But the quest for the perfect, in progressive approximations, is what separates science from fiction, opinion from evidence and guesswork from clinical medicine.
The opinions expressed here are solely my own as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
Visit Dr. Sederer's website for questions you want answered, reviews, commentary and stories.
A minuscule space separates health from disease and peace from pandemonium. It can be readily and rapidly crossed by a weapon of mass destruction that is invisible to the naked eye but possessing of a means of delivery that is ubiquitous and virtually unstoppable. The weapon is a virus and its weaponry human beings. It is by touch, breath, cough and sneeze that many a virus is transmitted: we put our hands to our face as many as 3,000 times a day -- after touching countless door handles, counters, dishes, and papers. The body count from a highly virulent strain depends upon what is called R-1 (or 2, or 4, or 8), the rate of its spread among its victims. Flu spreads at R-1, Smallpox R-3, and Polio R- 4-6. At a rate of R-4 the virus can infect 1 in 12 people on the planet (!) in a matter of months.
Pandemics, or epidemics of infectious diseases that impact very large numbers of people across great distances like countries or continents, are well known. Swine flu (H1N1), avian flu, SARS, smallpox, and polio, to name a few, can raise our emotional temperatures at the mention of their name. The so-called Spanish Flu of 1918-1919 killed 50 million people, more deaths than attributed to World War I. Their unpredictability is unnerving and their medical, social and economic costs can be incalculable. The telling of this macabre story in film is what "Contagion" exposes us to. When there is no known treatment and no vaccine, that's a potential body count in the hundreds of millions. That beats about any other scary movie I have seen.
This link will take you to a 2-plus minute animated video of how a "Virus Changes the World." Buckle your seat belt, and don't touch anything.
"Contagion" also packs a punch with its ensemble cast who are viral in their capacity to infiltrate the movie going public. There is Gwyneth Paltrow as the business woman/wife returning from Asia transporting the deadly disease; Matt Damon as the immune but bereaved husband determined to save his daughter; Laurence Fishburne as the Center for Disease Control and Prevention (CDC) chief on the case and Kate Winslet as the dedicated epidemiologist field officer sent to investigate the outbreak where Gwyneth released it; Marion Cotillard is dispatched from the World Health Organization (WHO) to Asia where the virus was born de novo and the contagion likely began -- actually called Ground Zero (and this film comes out immediately before the 10th anniversary of 9/11); Jude Law as the despicable blogger out to exploit whatever he can; and even Elliot Gould as the indomitable, salty scientist who no bureaucracy will deter.
Directed by Steven Soderbergh ("Traffic," "Erin Brockovich", "Ocean's 11" and its mutations) this film advances as fast as its subject. We are taken on a pandemic ride that churns up fear and will not be likely to forget. Which is, in part, what the film aims to achieve. Participant Media (see "Company with a Conscience") added its imprimatur and capital to this production to raise awareness of pandemics, identify and support the good guys, and help us all understand what can be done when faced with an enemy so powerful and merciless.
The war against a pandemic is waged on two fronts: the disease itself and the panic that ensues. Principles of containment for an infectious disease are well known: isolate the exposed, quarantine the sick and engage in a set of behaviors that prevent spread such as hand washing, covering coughs and sneezes, not touching just about anything, and the like. Then figure out what is causing the illness and how to treat and prevent it. Panic is another matter because it can give rise to primitive, mob behaviors where the rules of civilization and law seem also to have been destroyed by the disease. Still, social control can be achieved and most people will find the humanity at our core. We are a resilient lot, in body and mind.
It is a good thing we have science and government, one has to believe, at the end of this film. Where would we be without the CDC, the WHO, irascible and irrepressible scientists and a disciplined military used to preserve humanity, not destroy it? Where would we be without the National Institutes of Health to fund the basic research these medical (and military) soldiers need to do their job? Where would we be without responsible media that does not exploit human disaster but does what it can to help us all reach a higher moral ground? I just wish the filmmakers had been kinder to bloggers.
The opinions expressed here are solely my own as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
***** Originally posted on the Huffington Post on September 9, 2011
In response to the attacks on the World Trade Center in 2001, New York City and 10 surrounding counties mounted the largest and most effective mental health disaster response in history. Approximately 1.5 million people were served, receiving crisis counseling and education in their community settings. This massive endeavor was funded by The Federal Emergency Management Agency (FEMA) through a program called Project Liberty, which was overseen by the New York State Office of Mental Health and in New York City in conjunction with the New York City Department of Health and Mental Hygiene.*
Over the three years of Project Liberty's operation, $137 million was spent and more than 200 community agencies contracted to respond to the extraordinarily diverse population that constitutes New York City and its surrounding counties, with approximately 90 percent of the services delivered in New York City.
There was no cost to any Project Liberty recipients. More than 750,000 people received crisis counseling, and 740,000 people received public education. About 20 percent were children reached by community agencies in their schools and local neighborhood settings. Crisis counseling was provided to individuals and in groups. It was defined as emotional support in understanding a person's current situation, help in avoiding additional stresses and using healthy coping strategies, and linking impacted individuals with other persons and agencies to promote recovery. Education was defined as delivering direct information about common reactions to trauma, recognizing distress in children, stress reduction techniques and how to build coping skills. Education was also provided through mailings, print flyers and brochures, subway advertisements, newspaper articles and TV or radio spots. Direct victims of the attacks represented about 10 percent of individuals served and included those injured, evacuated or whose homes were damaged as well as family members of those who died in the attacks.
Perhaps the greatest lesson learned was that no one should go it alone in the face of disaster -- individual, community, city nor nation. An impressive level of governmental and community collaboration characterized Project Liberty, with a compelling sense of shared purpose. Were it not only in the wake of disaster that government entities played well together, and in unison with the private sector and citizens. One (of many) public messages conveying the need for trustworthy interchange was "Even Heroes Need to Talk."
Experience with trauma in the wake of disaster, particularly human-made disaster, was limited among the mental health community 10 years ago. While general principles of caring for people in mental distress existed, there were few professionals who had counseled disaster victims. Wide-spread training was needed and clinicians learned quickly. Some techniques proved to carry risk (like crisis debriefing) and over time a standard crisis approach has evolved that stresses careful listening to assess a person's response, capacity to cope and risk of self-destructive behavior: non-judgmental education that helps a person appreciate that their response may indeed be a "normal response to an abnormal situation," urging support from those an individual can trust, practical coping strategies (like getting sleep, not being alone, not abusing alcohol and drugs) and providing hope, since we know how resilient most people can be.
The media play a crucial role after a disaster. Responsible media need not endlessly loop pictures of a disaster (like the planes going into the towers) but instead can help raise public awareness that distress is common, even normative, and that seeking assistance need not be shameful. Because post-disaster distress and disorders (like depression, anxiety, PTSD and abuse of alcohol and drugs) can emerge many months after an event, public messages can be very useful when maintained over time. In fact, it is only over time that first responders (uniformed personnel, including fire fighters, police and EMTs) begin to suffer problems and need to be reached.
A problem in 2001 that continues today is that a FEMA-supported disaster response does not include treatment. FEMA's model, established by law long ago, has been that of rapid response and then transitioning out of an affected community. The Sept. 11 attacks and Hurricane Katrina serve as ample evidence that more than crisis response and education are needed. We were not able to provide, under Project Liberty, short-term counseling or even medications to help traumatized people sleep or quiet their overreacting nervous systems. This is a shortcoming that has yet to be corrected, though Project Liberty was given permission upon our request to employ brief (10-12 sessions) cognitive therapy for conditions like depression and anxiety.
Moreover, FEMA-supported services are based on the view that those people who do develop mental health and addiction disorders can be served by existing public and private services for these conditions. We don't need to go back to 9/11 to know today how under-resourced, fragmented and often broken the public mental health system can be, despite the talent and dedication of its clinicians and administrators (1,2).
Finally -- and here is some good news -- Project Liberty and every disaster response is about the people as much as it is about organizations and interventions. Individuals and communities are resilient. They need, however, adequate time and sufficient support services to foster resilience and the leadership to manage and to inspire hope (3).
*DISCLOSURE: From 2002-2007, I directed the mental hygiene division (mental health, addictions and mental retardation public mental health) of the NYC Department of Health and Mental Hygiene. Since 2007 I have been the Medical Director of the New York State Office of Mental Health.
I thank my many colleagues at the New York City Department of Health and Mental Hygiene and New York State Office of Mental Health for their work during Project Liberty, and fellow authors -- Ms. Lanzara, Dr. Essock, Ms. Donahue, Mr. Stone (who was Office of Mental Health Commissioner during Project Liberty) and Dr. Galea -- on a report about Project Liberty published in the Journal of Psychiatric Services.
The opinions expressed here are solely my own as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
Visit my website for questions you want answered, reviews, commentary and stories.
"Television has done much for psychiatry," Alfred Hitchcock remarked, "by spreading information about it, as well as contributing to the need for it." Hitch did not live long enough to become acquainted with the dizzying number of commercials for psychiatric medications that promise relief from suffering, performance enhancement and healthy outcomes. These ads always conclude with a plea to "ask your doctor about adding drug X to your regimen" followed by a breakneck telling of side effects and warnings called the "Fair Balance", required by the U.S. Food and Drug Administration (FDA). But just how fair and balanced is this type of advertising?
From 1962 to 1997, drug advertising was restricted to print advertisements. But in 1997 an FDA guideline opened up broadcast and Internet commercials to the pharmaceutical industry -- and Big Pharma responded with gusto. The now-familiar commercials for depression, bipolar disorder, social anxiety, and the like -- called "DTCA" for direct to consumer advertising -- are specifically targeted to the home viewer on a couch, rather than the psychiatrist in an office. (Interestingly, only the United States and New Zealand carry televised drug ads; the rest of the industrialized world has refrained.)
Appealing directly to the consumer at home has become a very lucrative business. Far more effective than advertising to doctors, drug companies spend an average of 4 to 5 billion dollars per year on DTCA. Moreover, reports indicate that pharma spends twice as much on advertising as on research and development (1). Pharmaceutical companies understand that profits accrue when viewers' interest in attractive products has been peaked and doctors are encouraged to be responsive to their patients. While broadcast advertising of psychiatric medications has boosted sales and filled the coffers of drug companies, we need to be concerned about what this costs consumers -- namely, all of us.
Pharma companies, in their own defense, contend that they are providing a public health service by educating consumers about a drug's potential benefits or the medical condition the drug purports to treat. But what about the potential public health risk that DTCA can unduly influence the consumer and impair the physician's decision-making skills? Can this lead to unnecessary, or worse, unsafe prescribing?
As consumer suspicion and awareness of hazardous side effects have grown over time, one would think that drug ads would decrease. Not so: Drug companies have, instead, increased their advertising budgets for riskier drugs in order to promote sales. This is called the "Inverse Benefit Law," a title coined by Drs. Brody and Light (2). The law says that the riskier the drug, the more pharma companies will allocate to its marketing, in order to boost sales of a drug. For example, a drug might effectively treat a condition from which a very limited group of patients suffer; but the company needs to sell the drug to a larger audience in order to cover its costs and achieve profits.
To increase sales, multiple strategies are used, including: exaggerating the benefits of a medication while minimizing the risk; encouraging "off-label" (or unapproved) use, despite limited evidence that the drug is effective for the "off-label" purpose; and exaggerating symptoms or even inventing new "diseases" -- such as excessive shyness, restless leg syndrome, or the ubiquitous sexual dysfunction. These claims expand the potential customer (or patient) population. In short, aggressive advertising of medications can produce a hazardous environment for patients.
Doctors as well as patients need to be alert to these marketing strategies. Physicians need to better understand the claims, studies and evidence put forth by pharma companies. If the "Inverse Benefit Law" is correct, the more heavily marketed the drug is, the more likely that studies and claims about it are apt to be biased. Physicians today need to be detectives (more like Lt. Columbo than Dr. House) and question the evidence: Who were the subjects in a trial, what benefits were shown, how rigorous a trial was done? Using medications "off-label" can be helpful in treating certain maladies, but doing so requires a firm knowledge of the scientific justification and the risks and benefits -- and underlines the critical importance of discussing this option fully with patients.
TV watchers are not the only ones misled. Psychiatry News recently reported that print ads in scientific journals also fail to report drug risks or provide demonstrable evidence (3). The FDA lacks the resources to be ever-vigilant, but they now offer a website to help physicians decode the tricks of the drug advertising trade and report any potentially illegal claims or promotions.
What can you do?
First, be an informed consumer. Don't believe everything you see on TV or read on the Internet. You need to know where to turn for trustworthy information. Go to websites by your state mental health agency or the National Institute for Mental Health, the National Mental Health Association and the National Alliance for Mental Illness. Google key words about what you want to know, as you would for breast or prostate cancer, diabetes or heart disease. Ask others who have successfully navigated the mental health care system and have taken medications.
Second, engage your doctor and other health professionals by asking questions about treatment (including, but not only, medication) and seek further opinions when you feel in doubt.
Third, consider approaches beyond pharmaceuticals. Medications are an integral part of the care for serious mental health disorders, but there are other effective treatments as well, including therapy, exercise, spiritual practices, and physical well-being.
"Fair Balance" requires more than speed-reading the risks of a medication while music is playing and a pleasant person is smiling at you from a TV screen. But that will not happen unless an informed consumer and prudent doctor team up. If they don't, they risk falling prey to DTCA and proving once again what P.T. Barnum said: "Never give a sucker an even break.".
(1) Gagnon M-A, Lexchin J, 2008 The Cost of Pushing Pills: A New Estimate of Pharmaceutical Promotion Expenditures in the United States. PLoS Med 5(1): e1. doi:10.1371/journal.pmed.0050001
(2) Brody, H. and Light, D.W. "The Inverse Benefit Law: How Drug Marketing Undermines Patient Safety and Public Health." American Journal of Public Health. 2011 Mar; 101 (3): 399-404.
The opinions expressed here are solely those of Drs. Erlich and Sederer, as doctors and public health advocates. Neither receives support from any pharmaceutical or medical device company.
Visit Dr. Sederer's website for questions you want answered, reviews and stories.
