Big Changes In Store For Psychology's 'Bible'
NEAL CONAN, host:
This is TALK OF THE NATION. Im Neal Conan in Washington.
The definition, diagnosis and recommended treatment for some medical disorders are in the process of revision. After 16 years, the American Psychiatric Association wants to update the bible of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders universally known as the DSM.
The new draft of DSM-V includes important changes to bipolar disorder, binged eating, autism and substance abuse, changes that affect not only mental health professionals and their patients but the insurance companies that also use the DSM as a guide.
Over the years, the DSM has generated controversy and criticism for what it defines as a medical disorder and what it doesn't. For example, homosexuality used to be listed as a disorder.
And the draft has been put out for comment from health care professionals and from the public. So here's your chance. Give us a call, 800-989-8255. Email us, firstname.lastname@example.org. How would these changes affect you? You can also join the conversation on our Web site. That's at npr.org. Click on TALK OF THE NATION.
Later in the program, post-earthquake triage with a Baltimore ER doctor just back from Haiti. But first, Dr.�David Kupfer, who chairs the DSM-V task force, joins us from his home in Pittsburgh, where he's also a professor of psychiatry at the University of Pittsburgh Medical School, and nice to have you with us today. I know you're snowed in, appreciate you taking the time.
Dr.�DAVID KUPFER (Chair, DSM-V Task Force; Professor, University of Pittsburgh Medical School): Well, not a problem. Thank you, Neal. If I could just reinforce what you've just pointed out, as you indicated, the last update to the DSM was in 1994, and there's been a tremendous amount of research since that time. There's also been, I think, a clarity with respect to the fact that a number of diagnoses did really not work well in real-life practice, and why were patients being diagnosed as often with NOS, not otherwise specified.
So we are really hoping that the criteria update, which is a proposed set of updates, would be more useful to clinicians and more accurately diagnose these patients.
CONAN: And let's get to that proposed thing. These are proposed revisions. This draft has been put out for comment. It would not take effect until after you've, well, had a chance to see what people say and then perhaps rewrite it again.
Dr.�KUPFER: Well, that's exactly what's going to happen. We're going to go through a process, really which I think is probably unprecedented, of after two months, reviewing all the commentary that comes from professionals and the public and patients and families and re-examine what we have as proposed criteria.
We'll be conducting some field trials in selected disorders to see how reliable some of these changes that we've proposed work out and how clinically useful and adaptable they are. Then we will probably have another public review of all this information before we really begin writing the final set of criteria and the text that goes with it because, in essence, this will not really be published officially until 2013.
Dr.�KUPFER: So we're hoping that this is a really important, (unintelligible) process, which will allow everybody to, in a sense, weigh in.
CONAN: Well, what are some of the big areas where you and your colleagues looked at practice and what was happening and saying look, we've got some problems here? This is where we need to focus.
Dr.�KUPFER: Well, clearly, we have some problems, and some of those problems are really across the entire age spectrum. I know that later on in the program, and really there have been two terrific stories already this morning on areas that relate to really childhood and adolescence, and that's the Asperger's issue with respect to autism spectrum and certainly pediatric bipolar.
But there are other areas that we felt, if you will, needed a lot of attention, and that's why there are proposals, and even major proposals, for changes. They include, for example, binge eating, which has been in the appendix of DSM-IV, but we really feel at this point, there's enough research and evidence to warrant its inclusion, if you will, in the main manual.
Issues of, for example, DSM-IV used the term mental retardation. There is important changes in the use of that term, and language is important. And so, for example, not only will we propose the use of intellectual disability, but we've included a number of criteria changes there to be more precise with when that diagnosis is appropriate.
Another area which I think is extremely important is this whole area of substance use and dependence. And there we've proposed a new category, which is addiction and related disorders, and this will include substance-use disorders, with each drug identified in its own category, but we will eliminate the category of dependence, which will give, I think, both clinicians and patients a better understanding of responses of tolerance or withdrawal when individuals are using prescribed medications.
Also coming out of this whole area of addictions is really the sense that there are behavioral addictions. We are recommending that perhaps gambling addiction be included in the main manual. There are several other...
CONAN: And that would obviously not be substance, and so that's one of the reasons for the change in the definition.
Dr.�KUPFER: Exactly. So what we would be talking about is really both what we would call drug or chemical and behavioral addictions because there's a very interesting set of neuroscience findings over the past 10 years which are suggesting that perhaps some of the underlying physiology and patho-physiology of these addictive disorders may not be terribly different between some of the behavioral addictions and the so-called, what I would call drug addictions.
CONAN: Well, let's start getting some of that public comment that you've asked for, 800-989-8255. Email, email@example.com. And Mark(ph) is on the line with us from Lexington in Kentucky.
MARK (Caller): Yes, I would just like to say that over the years, I have worked with psychiatric patients, and over the years, I've seen many patients come in against their will. And psychiatrists will typically find some sort of diagnosis in the DSM-IV that would fit just basically a personality trait. And I was thinking that maybe they should limit the amount of the entries in the DSM-IV to where psychiatrists don't necessarily have to pinpoint some sort of diagnosis for every patient they saw.
As a matter of fact, I think over the four, five years I worked in psychiatry, only a handful of patients, that were brought in against their will many times, left without a diagnosis from the DSM-IV. I think it's just too broad of a book. It needs to be a little narrowed down.
Dr.�KUPFER: Well, I - Neal, can I respond to that?
CONAN: Please go ahead.
Dr.�KUPFER: Yeah, sure. Thank you for that question. It gives me an opportunity to talk about one of the other issues that we have grappled with, which is this issue of, if you will, lumping things together or splitting.
Certainly, we're not interested in creating more diagnoses than currently exist in the DSM-IV. And the issue of personality and personality disorders has been something that has been of considerable work and interest to the group that's been working on personality, and it is very likely again, if one would go to the DSM Web site, you would see that what we are proposing is really one central diagnosis of personality disorders, rather than having the multiple personality disorder categories that we had previously.
What we hope this will do, if you would go to it, you would see that what we're describing is ways of talking about levels of severity and ways of assessing in a more precise way, such that not everybody, quote, "who has a personality trait" is going to get a case diagnosis.
And so I really agree with you that certainly, this was where we were going, with really, it was a bit there are several important areas where we need to be much more precise. We need to provide better assessments for clinicians. We need to be able to provide better information for patients and their families, and so therefore, we're in a much better position to, if you will, deal with appropriate interventions.
CONAN: Mark, thanks very much for the call, appreciate it.
MARK: Thank you, appreciate it.
CONAN: And Dr.�Kupfer was kind enough to mention reports that you've been hearing on NPR about two of the big areas, terms autism and child's diagnosis of bipolar disorder, and we've got the authors of those studies, of those reports, here with us in the studio. Those are Alex Spiegel, NPR science correspondent, and Jon Hamilton, also NPR science correspondent.
Jon, you've been focusing on autism, and there used to be in DSM-IV, there's a category called Asperger's disorder, and that's now going to be lumped in with a bunch of other things in a spectrum of autism.
JON HAMILTON: Right, it will be called the autism spectrum disorder, and it includes not just Asperger's but several other what used to be sort of sub-categories of autism. And as Dr.�Kupfer was saying though, the point here is to try to put things into that are similar into one category and then worry about severity of the symptoms rather than in having all these different buckets to put things in.
CONAN: And as you mentioned in your report, there are some people who have been diagnosed with Asperger's, say wait a minute, this has a distinguished tradition. There have been great people who have been known to have Asperger's, and suddenly, we're lumped in with some people who have very severe disorders.
HAMILTON: Yeah, this is a bit troubling for some people who have taken pride, and many of them call themselves Aspies(ph) or part of the Aspy(ph) community, and in fact, there have been, you know, famous people. Some great intellectuals probably would have been diagnosed with Asperger's.
So for these people, it's troubling, although it's interesting. I spent a lot of time today reading through blogs where people with Asperger's weigh in, and it's very mixed.
There are a lot of them that say, you know what? I've looked at the scientific evidence, and I think that we probably are all on the spectrum, and it's appropriate to put us there.
CONAN: Alix Spiegel, let me turn to you, and there has been an explosion of the number of children diagnosed with bipolar disorder, and some of the changes in this new draft of the DSM are directed to that.
ALIX SPIEGEL: Right. They want to create, or they are trying to create, a new category called temper disregulation disorder. And they are doing that, for exactly as you say, because they feel like too many children have been misdiagnosed as bipolar when they are not really.
CONAN: Because that's the only thing that was available to the psychiatrists under the in the old DSM?
SPIEGEL: Well, what happened was, I mean, the explosion of bipolar really dates to kind of 1995. And there was this woman named Janet Wozniak, who was working in this famous psychiatrist's lab, and his name was Joseph Biederman, and she was looking at kids with ADHD who really had problems with temper and, like, these terrible temper outbursts. And she interpreted their she decided that the real problem with these kids was not that they had impulse-control problems, because kids with ADHD sometimes have impulse-control problems, but that they had problems with their moods.
But in order to make that argument, and here this is what the people in the DSM say. In order to make that argument, she actually had to change the traditional definition of bipolar.
So before, to get categorized as bipolar, you needed to have episodes of mania, but she said the children don't have those kinds of episodes. They just have daily episodes. That was the change.
CONAN: This is what we're trying to address in the new draft of the DSM. Alix Spiegel and Jon Hamilton will stay with us. Also, more with Dr.�David Kupfer, chair of the DSM-V Task Force, 800-989-8255. Email, firstname.lastname@example.org. We want to hear some of that comment from the mental health professionals and the public on this proposed revision to this very important document. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.
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CONAN: This is TALK OF THE NATION. Im Neal Conan in Washington.
A new draft of the psychiatrist's bible, or the DSM, as it's known, was release by the American Psychiatric Association today. The DSM is used by mental health care professionals from psychiatrists to your insurance company to diagnose and classify mental disorders.
We're talking about why the changes are proposed, what they might mean, with NPR science correspondents Alix Spiegel and Jon Hamilton today. Also with us is Dr. David Kupfer, chair of the DSM-V Task Force and a professor of psychiatry at the University of Pittsburgh School of Medicine.
We want to hear the comments that they hope to hear from mental health professionals and from the public, 800-989-8255. Email us, email@example.com. You can also join the conversation on our Web site. Thats at npr.org. Click on TALK OF THE NATION.
Just before the break we were talking about those changes in autism and Asperger's and also child bipolar disorder, and Dr.�Kupfer, I know you had some comments.
Dr.�KUPFER: Yes, Both of these articles are excellent, as I've said before, and they highlight the fact that when we utilize all the scientific evidence and clinical trial and epidemiological data that was available, we came to the conclusion, with respect to Asperger's, that there was not the scientific evidence to make that separate, and so it is much clearer now and reflects our current knowledge of making this one larger disorder, Autism Spectrum Disorder.
With respect to the bipolar set of issues, what we found in two long term longitudinal studies now is that the children who have temper tantrums, impulse behavior and dysphoria that we've considered as this new syndrome have grown up to become individuals who develop anxiety and depressive disorders, not bipolar disorders.
And so what we're trying to do is make sure that pediatric bipolar disorder, if you will, breeds truly; these are individuals who are likely, if we don't intervene early, to have a lifetime illness, which we would consider bipolar disease.
CONAN: Let's get a caller in on the conversation. Scott joins us from Palo Alto.
SCOTT (Caller): Hi, very interesting discussion. I just was curious. It seems like the insurance companies would have a lot at stake here, and I was just wondering, during the public comment period, how do they weigh in? Is this committee lobbied by them, or how intensively are they lobbied by the insurance companies?
CONAN: It's written by psychiatrists for psychiatrists, but Dr.�Kupfer, the insurance companies sure do you use it, and do you take that into account?
Dr.�KUPFER: Well, they certainly use it, and like everybody else who will be able to, in a sense, go on to the DSM site, we expect that we may get public commentary from the insurance companies.
CONAN: But as Scott was asking, do the insurance companies play a role in decision-making? Are they part of the process?
Dr.�KUPFER: They are not part of the process.
CONAN: Scott, thanks very much for the call.
SCOTT: Thank you.
CONAN: And how much you know it's really important to people because they can get if it's in the DSM, they can get their insurance companies to pay for treatment of it, and so do you take that into account while you're writing this?
Dr.�KUPFER: Well, we want to make sure that patients who have a need for intervention and are suffering and have a level of threshold where they have dysfunctioning and impairment, deserve to receive care. That's the thing that is, in a sense, driving us, which is our patients and their families.
With respect to where the threshold is of disorder, it's not simply a number of symptoms, and I think that that's also important, that when we are dealing with our diagnostic criteria, we are trying to find the appropriate threshold of what we technically might call caseness(ph), but it's really those individuals who are seeking help and who need it.
CONAN: Dr.�Kupfer, thanks so much for your time today. We know you're busy, and this is going to be an interesting process. We'll be checking back in with you through the years.
Dr.�KUPFER: Thank you.
CONAN: Bye-bye. David Kupfer is chair of the DSM-V Task Force, professor of psychiatry at the University of Pittsburgh School of Medicine. Let's get some more callers on the line. Let's go to Steven, Steven with us from Tucson.
STEVEN (Caller): Hi.
CONAN: Hi, go ahead please.
STEVEN: Hi, my name's Steve. I'm a licensed psychology (technical difficulties) children primarily for the last 30 years as a special educator and a licensed psychologist. And I have to say I really appreciate (technical difficulties) work in the '90s with the diagnosis of children with bipolar disorder and how that kind of took off.
Generally, bipolar disorder is thought of as a, you know, neurotransmitter imbalance, and psychologists have kind of been left out of the loop...
CONAN: And does this redraft address your issues?
STEVEN: It does, and you know, I'm appreciative of that. It you know, my colleagues and I discuss it, how, how we had, you know, kind of been left out of treatment of children who get diagnosed with bipolar disorder.
CONAN: Steven, we're having trouble with your phone, so I'm going to have to let you go, but I will get a response from Alix Spiegel.
STEVEN: Thank you.
CONAN: Go ahead, Alix.
SPIEGEL: Well, I mean, he was saying that he it sounded like he was saying that he thought that the bipolar disorder was useful to him, and this new change essentially would what they are trying to do is make it more difficult for people to give the bipolar label to children. They think...
CONAN: Which would allow psychologists to work with some of these kids too.
SPIEGEL: Right, right, right.
CONAN: Here's an email, this from Judy in Vermillion, South Dakota. My nine-year-old son was denied services in my state of South Dakota because he was diagnosed as PDD-NOS, pervasive development disorder, not otherwise specified, a close relation to Asperger's. If he'd been diagnosed with autism, he would have received speech therapy, occupational therapy and other services. This new designation will do wonders for many children like my own who were penalized under the previous DSM. Is that one of the things, Jon Hamilton, it's meant to address?
HAMILTON: Indeed it is, and in fact a lot of the people that I spoke to who were looking at this were hoping exactly that thing would happen, is that kids who otherwise might have been dropped out of the system would be included because there is now a single diagnosis.
CONAN: Let's go to Elizabeth, Elizabeth calling from Nashville.
ELIZABETH: Hi, my comment is similar to the email you just read in regard to special-education services within the school system, and currently a child that has an Asperger's or a PDD diagnosis does not have those extra supports within the school context that they would if they were diagnosed with autism, even though they're very closely related disorders.
CONAN: And you're not concerned about the possibility of a kid who thought they had Asperger's now saying, oh, I've been tainted, painted with the broad brush of autism?
ELIZABETH: Having worked with autistic children, I don't foresee that as a problem, and I think it's something that will greatly benefit children on the entirety of the spectrum in social interactions and in their school environment.
CONAN: Okay, Elizabeth, thanks very much. Jon?
HAMILTON: One of the things that has been a problem with Asperger's specifically is that it's treated differently in different places in the country. So for instance, California may have you know, treats Asperger's separately, whereas other places may treat it more like autism, and I think one of the hopes here is that with single definition there'll be more uniformity from place to place in this country.
CONAN: It's interesting also because we think of autism, a lot of people may have heard Temple Grandin, when she's been on this program or on Terry Gross' program, saw the movie about her that was on HBO just last weekend, and realized what the spectrum of some of the differences of people's brains with autism really are.
Anyway, let's get another caller on the line. Celeste is joining us from St.�Louis.
CELESTE (Caller): Hi, this is Celeste.
CONAN: Yes, go ahead, please.
CELESTE: I am a psychiatry resident at Barnes-Jewish Hospital at Washington University. My question was about the new DSM-V. I know that the DSM-III kind of brought changes in the field of psychiatry. I was wondering how this DSM will change the field of psychiatry.
CONAN: Alix Spiegel?
SPIEGEL: Well, they've I think one of the things that they were shooting for was a little more continuity. I mean, the you mentioned the DSM-III. There was a huge change with the DSM-III from the DSMs that were before that. They introduced all of these criteria. But there's been a focus, I think, in this DSM with, you know, making it there have only been minor changes; not minor changes, but they have tried to limit the number of changes that they had from the DSM-IV.
CELESTE: How will this change psychiatry residency, do you think?
SPIEGEL: I'm not sure.
CONAN: We'll have to wait to see how that works out, and Celeste, thanks very much for the call.
CELESTE: Thank you.
CONAN: Bye-bye. Let's go next to this is Sara(ph), Sara with us from Gillette in Wyoming.
SARA (Caller): Hi. First of all, I want to say thanks for taking my call, but I have a nephew who is autistic, and his mother is always trying to find different things to blame, and she doesn't believe that he's autistic, and she doesn't think that he has the symptoms, but he's clearly autistic.
And I am really excited about this because I feel like if there's more symptoms listed, she might be able to finally understand that this is what he has and might be able to finally start working with him instead of ignoring him.
CONAN: Well, Jon Hamilton, some people, there is avoidance and denial in some cases. Obviously we don't know what the specifics are in this case, but nevertheless, is this new definition going to help parents of children understand what their children have?
HAMILTON: In some cases it will. I know one of the things that's been said among some of the people who have autism is that, you know, there's a group of people out there who really have what we have, but they say -and parents, for that matter, who say my kid doesn't - isn't autistic. They have Aspergers, or they have pervasive developmental disorder, and these things.
HAMILTON: And, in some ways, it clarifies things to just - instead of running around a label, just to say, okay. Here's the bright category. And the real question is: Where are the problems that they have trouble functioning? Is it just in social interactions, or is it in some sort of cognitive task? Where are the problems? Not what is the label you put on it.
CONAN: Okay. Sara, thanks very much for the call, and we wish your family the best of luck.
SARA: Oh, thank you.
CONAN: It sounds like you got some kids of your own, there.
SARA: Yeah, she's crawling around on the floor.
(Soundbite of laughter)
CONAN: Well, try to keep up with her. It's not so easy. Bye-bye.
CONAN: And let me turn to you, Alix Spiegel...
CONAN: ...and - some people have concern, particularly with this number of children who - and in the past, under the old DSM, have been diagnosed with bipolar disorder and the volume of powerful drugs that are being given to children who are quite young.
SPIEGEL: Yeah, that was one of the considerations that they talked about. The kids - even as young as two years old are getting mood stabilizers and this drug called anti - atypical antipsychotics. And, essentially, we have no idea. The drugs haven't been tested in children, for the most part, and we have no idea how this is going to affect them in the future, when they're 40, how this will affect them.
CONAN: Those longitudinal studies that...
SPIEGEL: They haven't been done, because, I mean, these drugs haven't really been used in kids until recently.
CONAN: There's also the question of control groups. You want to do blind studies, give it to some, and not to others. And ethical concerns come up there, too.
SPIEGEL: Mm-hmm. Exactly.
CONAN: So, is this addressed? How would that change under the proposed revision?
SPIEGEL: Well, it's a little bit hard to predict, is the answer. I mean, I think, you know, having talked to people who are behind the change, I think that they are hoping that by creating this new definition, people will be less quick to prescribe - psychiatrists will be less quick to prescribe the drugs for kids, and that they'll shift back towards, you know, more therapies, behavioral therapies, parenting advice. But it's impossible to say. I mean, the horse might be out of the barn on that one.
CONAN: The American psychiatric association has issued a draft of its proposed revisions to the DSM, the bible of psychiatry. It's out for comment from the medical professionals and from the public. It will be -those comments will be taken into account, and a final version will be out in 2013.
We're talking with Jon Hamilton and Alix Spiegel, NPR science correspondents. You're listening to TALK OF THE NATION from NPR News.
And here's an email from Larry in Independence, Missouri. While the DSM has useful for allowing consistency in treatment, it also has the negative effect of being a requirement for treatment. Modern scientific knowledge is not complete, and humans seem capable of demonstrating new behaviors as our environment changes, so it should not be surprising that some behaviors resist categorization. The negative side comes in when health insurance requires a hard diagnosis before providing coverage.
And, Jon, that's an issue that a lot of people bring up consistently with DSM's past, present and future.
HAMILTON: Indeed. And I should say that with autism, you know, for the most part, we're not talking about private health insurance, here, because there really isn't much private health insurance coverage for autism. It's not considered a medical disease that you can treat. Most of what we're talking about here has to do with getting support services from the government.
It has to do with disability. It has to do with special education, mostly. But, certainly, the problems that people have had in the past have to do with the fact that the understanding of the disorders has changed. And, you know, if this succeeds in doing - in being more precise in saying who's in, who's out...
HAMILTON: ...it will have been a good thing.
CONAN: Let's go to Jim, Jim calling from San Antonio.
JIM (Caller): Yeah. How are you doing there?
CONAN: I'm well, thanks.
JIM: My question is more about mental health and the positive side. When I was in school, the DSM-IV revised edition was out. You know, obviously, it's changed a lot since. But my main issue has been how there's never been a definition of what mental health is. Abraham Maslow did extensive research in that area, but all his work is pretty much been completely ignored by the psychological community. And I was - I think it would be great if they put a definition of what mental health is in the book.
CONAN: Is that going to be addressed, Alix?
SPIEGEL: Mental health or mental disease?
CONAN: No, mental health. In other words...
JIM: Mental health.
CONAN: ...they're defining a lot of things about...
CONAN: ...what can go wrong. Are they saying - and here's a description of somebody who's - well, shall we say sane?
(Soundbite of laughter)
SPIEGEL: I haven't heard that they're coming up with one anytime soon, but, you know.
CONAN: Well, there is - there are movements, the positive psychology movement...
SPIEGEL: Right, exactly.
CONAN: ...which does say, wait a minute...
SPIEGEL: Let's look at peoples strengths.
CONAN: ...let's look at people's strengths and not at people's weaknesses. And does this address that at all?
SPIEGEL: The DSM really doesn't look at mental health. It's really looking at mental dysfunction and trying to, you know, carve out all -like, define all of the different kinds of mental dysfunction that exist.
CONAN: And, Jon Hamilton, as we - thanks very much for the call, Jim. Evidently, the answer of your question is no. But, as we look down the road, this period of comment and experimentation, this is going to be a vital period on the next few years.
HAMILTON: Indeed, it will be. I mean, I think - the comment period for over the next couple of months is going to be very interesting because it's clear that there are - certainly from people with autism and Aspergers, there's going to be a lot of feedback here. And then - and a lot of these people bring up some really central issues, as they point out, you know, here why Aspergers, for instance, has been a good thing...
HAMILTON: ...for these people. And maybe that's reason enough to keep it. One of the interesting things I heard from some of the books of the American Psychiatric Association is that they are going to consider all of those things - not just scientific things, but they are considering the social and political impact.
SPIEGEL: Which is really - presents a potential problem for them, I thought, because - you know, I mean, one of the things that they've done - and you heard this with Dr. Kupfer, who said, look. This is a really scientific document. It's a - it is science. So if they open it up to the floor and you get kind of interest groups, political interest groups like, you know, like Asperger's interest groups or a bipolar group saying, no, don't make these changes, if they make the changes, will it undermine the scientific credibility of the document? That's part of the question.
CONAN: And these are issues that Alix Spiegel and Jon Hamilton will be following for us on NPR News over the coming months. They're both science correspondents here. And we thank them for their time today. We really appreciate it.
SPIEGEL: Thank you.
HAMILTON: My pleasure.
CONAN: Coming up, the earthquake in Haiti caused hundreds of thousands of injuries. Health care workers had to make life-and-death decisions every day. Dr. Michael Millin just returned from Port-au-Prince. Well talk with him about those triage decisions and how they differ from those he has to make every day at an ER in Baltimore.
Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.
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