From Last Class

1. Diagnosing Mental Disorders and the DSM PSYC 4500: Introduction to Clinical PsychologyBrett Deacon, Ph.D.September 12, 2013

2. From Last Class • Essential features of science and pseudoscience

3. Schedule • Today: Diagnosing mental disorders (response paper due – please turn in now) • Next Tuesday: psychological and biological theories (Satel & Lilienfeld response paper due) • Next Thursday: Exam 1

4. Questions for Kirk, Gomory, & Cohen (2013) Chapter, due today • List and describe what you believe to be the three most significant problems associated with the DSM diagnostic system raised by the authors.

5. Questions for Satel & Lilienfeld (2013) Chapter, due next Tuesday • List and describe what you believe to be the three most significant problems associated with the brain disease theory of addiction raised by the authors.

6. Chapter 5: Diagnosing Mental Disorders • Note: pp. 128-133 only for exam 1 • Primary role of clinical psychologists • The tension surrounding diagnosis: scientifically questionable vs. practically indispensable • Diagnostic and Statistical Manual of Mental Disorders (currently DSM-5)

7. Evolution of the DSM • History of the DSM • 5 editions, I in 1952 through IV in 1994 • Now 6 editions, with DSM-5 in May of 2013 • Massive changes in length and content

8. DSM-5 (2013) DSM-IV-TR (2000) DSM-IV (1994) DSM-III-R (1987) DSM-III (1980) DSM-I (1952) DSM-II (1968)

9. Number of Diagnoses by DSM Edition

10. DSM-III: The First Modern DSM • “Atheoretical” symptom-based diagnosis • Elimination of psychoanalytic concepts

11. Atheoretical Diagnosis • Diagnostic criteria focus on symptoms, not on their presumed underlying causes • Improves diagnostic reliability (in theory) • Why?

12. Atheoretical Diagnosis • Is the DSM diagnostic system really atheoretical? • The DSM assumes mental disorders: • Are categorical entities, not dimensional • Are distinct from each other • Most likely reflect biologically-caused conditions • Have symptoms that may be diagnosed without considering the context in which they occur

13. Diagnosing Mental Disorders • Multiaxial system • Axis I: Clinical syndromes • Axis II: Personality disorders and characteristics and mental retardation • Axis III: Medical conditions • Axis IV: Psychosocial and environmental stressors • Axis V: Global assessment of functioning

14. Case Example Amy is a 21-year-old nurse. She has been experiencing unexpected panic attacks on a daily basis for two months. She avoids situations that might trigger a panic attack, particularly those in which she would not be able to get help or escape would be difficult. Amy has asthma and fears that a panic attack will escalate into a fatal asthma attack. She has left work, or avoided coming to work, on numerous occasions in the past two months and is in danger of losing her job if her absenteeism continues.

15. Diagnosing Mental Disorders • Amy’s Diagnosis • Axis I: Panic Disorder with Agoraphobia • Axis II: No Diagnosis • Axis III: Asthma • Axis IV: Occupational problems • Axis V: GAF = 55 (Current)

16. Diagnosing Mental Disorders • Advantages of diagnosing: • Enhanced communication between professionals • Facilitates study of causes and treatments of specific disorders • Helps in treatment planning • Necessary for insurance reimbursement

17. Diagnosing Mental Disorders • Disadvantages of diagnosing: • Add little to our understanding of a problem; describe symptoms but do not explain them • Suggests the presence of a disease state • May stigmatize patients and invite discrimination • Many diagnoses have poor reliability

18. Diagnostic Reliability • Kappa (inter-rater reliability) = degree to which two clinicians independently agree on presence or absence of a diagnosis when the same patient was interviewed on separate occasions, in clinical settings, using usual clinical interview methods (Regier et al., 2012) • Percentage agreement adjusting for chance

19. DSM-5 Field Trials • What degree of interrater reliability do you think is acceptable for DSM diagnoses?

20. DSM-5 Field Trials: Reliability “Historically, kappas above 0.8 are considered good, above 0.6 fair, and under 0.6 poor. Before [now], no one has ever felt comfortable endorsing kappas so low as 0.2-0.4. As a comparison, the personality section in DSM-III was widely derided when its kappas were around 0.5. A kappa between 0.2-0.4 comes dangerously close to no agreement.” -Allen Frances, editor of DSM-IV

21. DSM-5 Field Trials:Interrater Reliability of Selected Diagnoses

22. Interrater Reliability of DSM-5 Diagnoses

23. Interrater Reliability of MDD and GAD

24. On the Low Reliability of MDD and GAD • Explanation for DSM-5’s poor reliability: • “…as part of that [DSM-IV process], patients were carefully screened, and participating clinicians received special training and explicit direction on how to perform evaluations. In contrast, the DSM-5 field trials accepted patients as they came and asked clinicians to work as they usually did – to mirror the circumstances in which most diagnosing takes place. We believe the DSM-5 results represent the truer picture of the difficulty clinicians may have in reliably diagnosing both conditions…” – Kupfer & Kraemer (2012)

25. On the Low Reliability of MDD and GAD • Were interrater reliability estimates in previous DSMs inflated? • Are the DSM-5 figures more accurate? • If so, what are the implications?

26. DSM-5 Process: Public Criticism • Unprecedented criticism for a DSM • Harsh criticism from Robert Spitzer and particularly Allen Frances • Statement from British Psychological Society • Letter from American Counseling Association • “Dx Revision Watch” • “Boycott DSM-5” • Critical stories in popular media

27. DSM-5 Process: Public Criticism • “Open Letter to the DSM-5” • Signed by 14,600 individuals • Sponsored by > 50 organizations including: • Society for Humanistic Psychology (APA) • British Psychological Society • Division of Clinical Psychology (APA) • Division of Psychotherapy (APA)

28. DSM-5: Major Criticisms • Comments about DSM-5 from Allen Frances, M.D., Chair of DSM-IV • http://www.youtube.com/watch?v=yuCwVnzSjWA (19:06 to 26:05)

29. DSM-5: Major Criticisms • Medicalization and stigmatization of normative experiences • Diagnostic inflation and false epidemics • Facilitates unnecessary exposure to potentially harmful medications • Over-emphasis on biological theory • Lack of validity of diagnostic categories and categorical approach to diagnosis

30. Controversy: Conflicts of Interest among Task Force Members • In 2012, DSM-5 website published list of potential financial conflicts among 29 task force members for prior 3 years • 21 of 29 members had > 1 conflict • Average = 9.6 conflicts • Majority were with pharmaceutical companies Pilecki, Clegg, & McKay (2011)

31. Self-Reported Financial Conflicts of Interest among DSM-5 Task Force Members Pilecki, Clegg, & McKay (2011)

32. Controversy: Conflicts of Interest among Task Force Members • Why might financial conflicts of interest with pharmaceutical companies among DSM-5 task force members be controversial? • What effects might they have on DSM-5?

33. Unprecedented Criticism • To what extent do controversies surrounding the DSM-5 involve the DSM vs. the 5? • Has the field reached a tipping point?