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DSM-5

DSM-5. Allen Frances MD. DSM IS A Guide NOT a Bible. •Criteria sets needed for reliability •May help sort out faked presentations •But nothing sacred about items or thresholds •Many presentations are atypical. DSM Has Many Purposes. •Clinical •Research •Education •Forensic

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DSM-5

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  1. DSM-5 Allen Frances MD

  2. DSM IS A Guide NOT a Bible •Criteria sets needed for reliability •May help sort out faked presentations •But nothing sacred about items or thresholds •Many presentations are atypical

  3. DSM Has Many Purposes •Clinical •Research •Education •Forensic •Eligibility for Treatment and Disability

  4. DSM Forensic Cautions •What works in clinical situation may not make sense in forensic •Definitions of insanity and criminal responsibility differ over time and jurisdiction •Legal definitions don't closely follow DSM disorder but have no other standard

  5. Both Sides Of 'Mad' vs. 'Bad' • Garfield assassin • Hinckley • Unabomber • Norwegian mass murderers • Terrorists VS V S

  6. Dangers of DSM 5 • Would greatly increase over diagnosis and over treatment • Medicalize normality- drug company feeding frenzy • Medicalize criminality- forensic nightmares and abuse of psychiatry

  7. DSM 5 Suggestions All Lower Thresholds • Tens of millions of false positives  • No effective treatment  • Side effects and stigma  • Enormous cost • Misallocation of resources

  8. New Diagnoses Can Be Dangerous As New Drugs • High false positive rates  • Dangerous over medication  • Public health cost and misallocations  • Stigma  • Trivialize psychiatric diagnosis  • Medicalize normality  • Reduce individual responsibility  • Create sick society

  9. Experts Bias Leads To Over Diagnosis • Naturally favor pets • Worry too much about false negatives • Worry too little about false positives • Narrow focus and training • No expertise in everyday clinic or primary care • No expertise in public health • No expertise in health economics

  10. Will DSM-5 Affect Work In Prisons? • Not much • Issues relate mostly to the boundary between mental disorder/normality- not severe illness • Redefining rape as mental disorder was rejected

  11. Substance Use Disorders • Lumps Abuse and Dependence • Stigmatizes the non-addicted • Different outcome and prognosis

  12. Behavioral Addictions- bad idea • Starts with Gambling • Internet Addiction in Appendix • Why not sex, work, shopping, jogging, golf, model railroads, the sun • Not all passions are addictions

  13. Adult ADHD • Too inclusive • R/O normal and psychiatric causes • Free pass to speed • Neverdiagnose in prison

  14. Temper dysregulation • Goal to reduce childhood bipolar • Other better ways to do this • Will cause more misuse of meds • Little research support

  15. Autistic spectrum • Rates 1/2000 to 1/50 • Relabeling- not more sx or vaccination • DSM5 Autistic Spectrum narrows definition- not clear how much

  16. Somatic Symptom Disorder • Wildly over-inclusive • 25% pain; 15% cancer; 7% healthy • Missed medical and psychiatric disorders • Stigma • Lost benefits

  17. Bereavement Exclusion • Two weeks of mild symptoms • No problem needed fixing • Over-treatment with meds • Reduces dignity of grief

  18. • Opens up stressor criterion • Abuse in forensic arena • Why easy to over-dx • Why easy to miss

  19. Mild Neurocognitive Disorder • Why not wait until biological test • High false positive rate • No treatment • Cause needless worry and stigma

  20. Binge Eating Disorder • 1 binge per week for 12 weeks • Little research • No effective treatment • Promote over-use of meds

  21. Dodged Bullets • ParaphilicCoercive Disorder • Hypersexuality • Hebephilia • Dimensional DC of Personality     

  22. Conclusions • Be cautious and tentative • Under-dx rather than over-dx • Re-evaluate and get second opinions • Use meds only for clear reasons • Avoid polypharmacy • FIRST DO NO HARM

  23. Dimensional Diagnosis • Numbers vs. names  • More accurate  • Less vivid and convenient

  24. DSM 5 Gives Dimensions A Bad Name • Ad hoc • Impossibly cumbersome  • Time consuming  • Clinically unfriendly • Will never be used

  25. The hope of the future- NIMH RDoC project to correlate  behaviors with neural networks • Negative affect(fear, stress, and aggression) • Positive affect (reward/habit) • Cognition (attention, perception, memory, language, behavior, and self control) • Social processes (imitation, dominance, facial expression, identification, attachment/separation, and self-representation) • Arousal/regulatory • processes

  26. Who Should Make Decisions • APA  • WHO  • NIMH •  Inclusive FDA type process with input from researchers, epidemiologists, clinicians, educators, primary care, forensics, health economists, public health experts

  27. How Should Decisions Be Made? • Science base   •  Utilitarian pragmatism  • Public policy-resource allocation  • Necessarily somewhat arbitrary

  28. DO NO HARM

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