Diagnostics tome comes under fire.the reliability found in the field studies of DSM-5, is pretty poor (as measured using the Kappa coefficient). Omino

NATURE | NEWS

Diagnostics tome comes under fire

Field tests of new criteria are flawed, critics argue.

•Heidi Ledford
31 January 2012

Diagnoses of certain mental illnesses could rise significantly from next year, say some mental-health experts — but not because of any real changes in prevalence. Instead, the critics blame what they say is a flawed approach to testing the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the standard reference used by researchers and mental-health professionals in the United States and many other countries to assess patients, inform treatment, design studies and guide health insurers.
Changes to the diagnostic criteria in the fifth edition of the manual, DSM-5, due to be published in May 2013 by the American Psychiatric Association (APA) in Arlington, Virginia, have raised concerns that some disorders will be overdiagnosed (see Contentious proposals for DSM-5). Critics say that the analysis of field tests of the new criteria won’t settle those concerns.
Trials of DSM-5 conducted at 11 academic centres were completed last October. In a Commentary published in the American Journal of Psychiatry (H. C. Kraemer et al. Am. J. Psychiatry 169, 13–15; 2012), members of the task force explained that the aim was not to focus on the frequency of a given diagnosis under the proposed DSM-5 criteria compared with that under the previous criteria. Because there is no accepted prevalence for most psychiatric disorders, they argued, it would be impossible to tell whether a rise in diagnoses reflects a true increase in the sensitivity of the revised criteria or simply a rise in the number of false positives.
That raised the hackles of some researchers, who say that without such comparisons it will be impossible to flag up the possibility that some categories will show an increased prevalence. “It’s a real step back,” says Thomas Widiger, a psychologist at the University of Kentucky in Lexington, who notes that trials of DSM-IV were careful to compare old and new diagnostic criteria to see which performed better.
Allen Frances, emeritus professor of psychiatry at Duke University in Durham, North Carolina, led the 1994 DSM-IV revision and is an outspoken critic of DSM-5. Frances acknowledges that the field trials for DSM-IV were far from perfect. For example, his trials failed to identify the dramatic surge in diagnoses of attention-deficit/hyper¬activity disorder that followed changes made in DSM-IV. The trials suggested that there would be an increase of about 15% in the disorder. Instead, says Frances, the diagnosis rose threefold. “We missed the boat,” he says. “But at least we had some sense that there would be an increase.”
Results from the DSM-5 academic field trials have yet to be presented, but early calculations suggest that, in general, there will be no big differences in the frequency of diagnoses, says Darrel Regier, vice-chair of the DSM-5 task force and APA director of research. That claim has done little to alleviate concerns, however, because the trials enrolled patients who were initially diagnosed under DSM-IV standards. This leaves untested the possibility that the DSM-5 criteria will capture many more patients who were previously deemed healthy, notes Widiger.
Observers are also alarmed by the statistical thresholds that the trials used to assess reliability, or the likelihood that two or more clinicians would arrive at the same diagnosis using the proposed criteria. This likelihood is often expressed as a statistical term called ‘Cohen’s kappa’. A kappa of 0 means that there is no agreement between the clinicians; a value of 1 means that the clinicians agree totally.
Researchers in the field often strive to reach a kappa of 0.6–0.8, indicating that the independent diagnoses agree more often than not. But in the Commentary, lead author Helena Kraemer, an emeritus statistician at Stanford School of Medicine in California, argued that a kappa of 0.2–0.4 could sometimes be acceptable. Kraemer later elaborated to Nature that the task force was largely aiming for a kappa of 0.4–0.6, but that it wanted to prepare the field for seeing values as low as 0.2 in particularly rare diagnoses or in those without biological markers.
Unlike tests on the previous edition, the reliability tests on DSM-5 were performed on separate occasions, so that the clinicians involved were unaware of each other’s diagnoses. Widiger says that he supports the more rigorous approach, but that accepting a value as low as 0.2 gives him pause. “I’ve never seen anybody argue that a kappa of 0.2 is acceptable,” he says. “You just can’t get much lower than that.”
Not everyone is worried about a surge in diagnoses. Thomas Frazier, a paediatric psychologist at the Cleveland Clinic in Ohio, has carried out his own study of DSM-5 criteria for autism spectrum disorder. His results, published online last year (T. W. Frazier et al. J. Am. Acad. Child Adolesc. Psychiatry 51, 28–40; 2012), suggested that the new definition would omit some patients with autism, but that this could be easily corrected by requiring one less symptom to meet the threshold for a positive diagnosis. “Unfortunately, the DSMcommittees are not systematically doing these kinds of studies,” he says.
Nature Volume: 482, Pages: 14–15 Date published: (02 February 2012) DOI: doi:10.1038/482014a

The Return of Hysteria

This is an interesting piece of information... I think that they got the bit about Gilles de la Tourette wrong. However, I feel that it is interesting how hysteria is becoming "fashionable" again.

Perhaps you would like to initiate a debate in the blog about the return of hysteria...






The Return of Hysteria?
via Advances in the History of Psychology by Christopher Green on 1/29/12


Hysteria is a condition strongly associated with the 19th century, and with long-past historical figures such as Jean-Martin Charcot and Sigmund Freud. It was finally dropped from the psychiatric vocabulary in the mid-20th century because of its uncertain scientific basis, and because of the widespread perception that it was being used more as a way to control the behavior of women who did not conform to social norms than to label a coherent psychiatric condition.

A recent column in the New York Times, however, suggests that hysteria has made a comeback in the very same population that it was thought to be most prevalent in in times long past: teenage girls and young women. Author Caitlin Flanagan recounts the story of “a high school cheerleader” in a town near Buffalo, NY, who “lay down for a nap,” last October “and woke up changed…. facial tics, uncontrollable movement, stuttering, verbal outbursts.” She continues, “several other schoolmates have been afflicted, for a total of 14 girls. One boy reported symptoms.”

It turns out that this bizarre event was not an isolated incident. Flanagan goes on to described similar happenings in 2002, in the 1980s and in the 1960s, in the the US, the UK, the Middle East, and in Africa. Flanagan recognizes that the diagnosis of “hysteria” is “unpalatable in our post-Freudian age”; that it “is the most retrograde and non-womyn-empowering condition. She goes on, “It’s not supposed to happen anymore,… but it won’t seem to go away.”

The column concludes with an anodyne call for a “stable and supportive space in which [teenage girls can] “work out all of this drama.” But the question of whether the hysteria of old still occasionally stalks the land despite our efforts to banish it remains unanswered.

Mindfulness

I am currently partaking in the mindfulness course offered at Queen’s. I must admit, I was a bit apprehensive about attending this course. I wasn’t sure how beneficial it would be. Would it be worth spending one evening each week practicing mindfulness? 

I have learned many hard truths about myself in my short life. I have learned that I need to put myself first for I cannot expect my significant other or my family to do so especially if I do not. I have learned that my innate worth remains the same no matter what happens to me. I have learned that life is short and I need to appreciate all the good moments as they come. I have learned that I need not expect things to get better ten years from now. What matters is the here and now.

Mindfulness has taught me a few new things. Today, my second day at the course, I left feeling fulfilled. I left with an inner sense of peace and well being. I left feeling whole. No negative thoughts invaded my conscious tonight. I was mindful of the wind on my face. The cold, the sweet fusion, the wonder of taste in my mouth as I drank a strawberry milkshake on a cold winter night. I am aware of the warmth around me as I sit enveloped in my cocoon at home. I am here in the now.

I am present. 

Resident’s Retreat

This year's residents' retreat was extremely well attended, both by juniors and seniors. The day started with a round table evaluation of all the supervisors in the program, continued on to a lunch at a Greek restaurant and then after a lively discussion on several topics pertaining to our curriculum, everyone gathered for dinner at Aquaterra. Everyone got the chance to catch up as colleagues in a relaxed and friendly atmosphere with amazing food and beverages.

A Brief Guide to the DSM

The British Journal of Psychiatry’s ’100 words’ series continues with a very brief guide to the DSM psychiatric manual and its ongoing revision.

DSM is an American classification system that has dominated since 1980. It is disliked by many for reducing diagnostic skills to a cold list of operational criteria, yet embraced by researchers believing that it represents the first whiff of sense in an area of primitive dogma. It has almost foundered by confusing reliability with validity but the authors seem to recognise its errors and are hoping for rebirth in its 5th revision due in May 2013. The initials do not stand for Diagnosis as a Source of Money or Diagnosis for Simple Minds but the possibility of confusion is present.

I was very pleased to see that the British Journal of Psychiatry made quite clear that the DSM is an American invention.

The original British plans, of course, were to have psychiatric diagnoses based on measuring the stiffness of one’s upper lip – an objective and reliable approach that was sadly neglected.

Link to British Journal of Psychiatry’s DSM in 100 words.

DSM V: bereavement vs major depressive episode

We recently had a lecture that touched on the removal of the bereavement exclusion criteria from the diagnostic criteria for a Major Depressive Episode (MDE).

Secret Santa

Queen’s psychiatry residents had their first ever Secret Santa this year. Over eighteen residents participated. One gift within 10 dollars. It was a great success. It is amazing what 10 dollars and a little imagination can come up with. KUDOS Queen’s psychiatry residents! Ho Ho Ho...