Psychotherapy Brown Bag

More DSM-V Talk

by Michael D. Anestis, Ph.D.

DSM-V is certainly in the news these days.  Recently, the folks responsible for developing the forthcoming new edition of the diagnostic manual announced that they were backing off their plans for two potential new diagnoses, a decision that was met with widespread applause.  Now, Allen Frances has reported that, at the annual APA convention, data regarding the reliability of the proposed diagnostic structure for DSM-V from the field trials are now available and the results are....horrifying.

A little history here.  In the first two editions of the DSM, diagnoses were generally described in vague terms that emphasized symptoms that were difficult to assess and measure with any consistency.  In this sense, the writers of the early manuals did not place much of a premium on reliability, which in this particular sense refers to the degree to which two clinicians who assess the same patient will agree on the presence or absence of a particular diagnosis.  When DSM-III came around, psychodynamic jargon and other unclear phrasing was removed and a heavy emphasis was placed on behavioral indicators and other symptoms that could more reliably measured.   In doing this, they vastly increased the reliability of the diagnoses in the manual, although some feared that, as a result, they decreased the validitiy (in this case, validity refers to the degree to which the diagnosis as described actually represent the diagnosis as it occurs in reality).  To some extent, increasing reliability can require a decrease in validity (e.g., I might removed a confusing criterion that truly is a part of the disorder in order to increase the likelihood that people will agree whether or not somebody has that disorder).  This is a particularly important issue to consider with the present controversy.

Back to the present.  Dr.Frances reported that the kappa values - a measure of agreement between clinicians as to whether or not an individual meets criteria for a diagnosis - were just awful for a large number of disorders.  For instance:

• Depression - kappa = .32
• Generalized anxiety disorder - kappa = .2
• PTSD - kappa = .67
• Autism spectrum disorder - kappa = .69
• Antisocial personality disorder - kappa = .22
• Obsessive-compulsive disorder - kappa = .31

To give some context to those numbers, kappas of .4 have historically been considered "poor," and, indeed, the results of the DSM-III field trials left the authors of that decision confident that kappas below .6 would be a cause for concern (Spitzer, Williams, & Endicott, 2012).  Frances put forth a number of potential explanations for the problematic data for DSM-V diagnostic categories.  Amongst his arguments were:

• Nobody on the DSM-V committees was capable of developing clearly worded and succint diagnostic criteria and, as such, the wording was a recipe for disaster (and the results forseeable)
• The complexity of the procedures involved in the DSM-V field trials was over the top, again setting folks up to fail
• A second stage of the field trials in which poor data would be addressed through revision and further data collection was canceled due to timing and financial issues (as well as the need to meet publication deadlines).

From what I've read, there is near universal concern about these results within the field.  Some authors have noted that traditional standards for kappa evaluation are unrealistically high and that the new diagnoses might need to sacrifie some reliability for validity (e.g., Kraemer, Kupfer, Clarke, Narrow, & Regier, 2012).  Looking at these numbers, however, you have to wonder whether too much of one is being sacrified for unknown levels of the other.

Issues like this concern me for a number of reasons.  First, the obvious.  It doesn't look good for our field when, in an effort to enhance the scientific and clinical value of our diagnostic system, we create a system that yields chaotic levels of disagreement amonst clinicians regarding whether or not a particular disorder is present.  Nobody expects perfection on that front, but we need to not be lowering the bar at this point.  Second, I feel as though this might increase the strength of calls to abandon diagnostic systems entirely.  Although I obviously sympathize with the sentiments behind not "labeling" folks who are struggling, a properly developed and implemented diagnostic system doesn't do that.  What it does is create a single language that all researchers and clinicians can speak with respect to the presentations of individuals struggling with mental illness.  Doing this allows for systematic research on particular treatments, trajectories of particular symptom clusters, and other important issues, thereby enabling accountability with respect to what clinicians should and should not do for their clients.  Although a poor diagnostic system will pathologize normal processes, a lack of diagnostic system will result in chaos (e.g., without a diagnosis, which treatment will be used and how will we assess success and to whom will the results of such treatments be compared?).  In a sense, I see this almost as an argument to strive for a good government rather than choosing anarchy when the government proves imperfect.  We need a system within which to work - the fact that so many individuals out there practice sham treatments even WITH data pointing towards better options should speak clearly to our inability to function effectively without guidelines.  Don't get me wrong here, - I'm not suggesting that this outcome is anywhere close to happening.  I just think that missteps like this result in increased energy being spent on issues unlikely to move us forward, so in the end, we all lose.

DSM-V is not a simple issue and a lot of brilliant and well-intentioned people vehemently disagree on these issues. How this all plays out will have an enormous impact not only on those of us working within the field, but everyone in the world who struggles with mental illness.

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Dr. Mike Anestis is an incoming assistant professor in the Department of Psychology at the University of Southern Mississippi

Articles cited in this post:

Kraemer, H.C., Kupfer, D.J., Clake, D.E., Narrow, W.E., & Regier, D.A. (2012).  Response to Spitzer et al letter.  American Journal of Psychiatry, 169, 537-538.

Spitzer, R.L., Williams, J.B.W., & Endicott, J. (2012).  Standards for DSM-5 reliability.  American Journal of Psychiatry, 169, 537.

Patients view structured diagnostic interviews more positively than clinicians believe they do

by Michael D. Anestis, M.S.

When a patient is assessed for the presence of mental illness, the interaction can look very different from setting to setting.  One of the primary sources of potential differences is the degree of structure involved in the assessment.  Structured diagnostic interviews, which involve a series of questions designed to systematically assess for the presense of specific mental illnesses, have emerged in recent years as a method for developing accurate and reliable diagnoses and for making difficult differential diagnostic decisions (e.g., Basco et al., 2000; Zimmerman & Mattia, 1999).  Scientifically-minded psychologists - in large part - agree that using these structured interviews is the gold standard method for ensuring a valid and reliable diagnosis (Joiner, Pettit, Walker, Perez, & Cukrowicz, 2005).  Another approach, however, involves the use of unstructured interviews.  In this latter approach, the clinician simply asks questions that seem relevant, developing the interview as he or she goes in an effort to determine the precise nature of a patient's diagnostic profile.

Nearly two years ago, I wrote an article on PBB discussing a study published in Behavior Therapy that examined the degree to which patients respond positively to structured interviews.  This study was needed because, despite empirical evidence supporting the greater reliability and validity of structured interviews relative to unstructured interviews, there appeared to be substantial resistence to their implementation in every day practice, some of which stemmed from clinicians' concern that patients view structured approaches negatively.  As it turns out - and you can read much more detail about this in the original PBB article - patients actually viewed the structured interview extremely positively.  On average, they found the interview to be helpful and not overly exhausting and they reported that their relationship with the therapist who administered the interview was very positive.

Today, I came across a follow-up study by the same research group (Katrin Bruchmuller, Jurgen Margraf, Andrea Suppiger, and Silvia Schneider) that is currently in press at Behavior Therapy.  In this study, the authors wanted to accomplish three main goals:

1. Determine the degree to which structured interviews are utilized in every day practice
2. Compare therapists' views of patients' views of structured interviews to the actual patients' views of structured interviews
3. Determine the reasons that therapists do not utilize structured interviews and the degree to which specific reasons are associated with not using structured interviews

This particular research team is based in Switzerland and, to access therapists, they utilized the email lists of the three main professional organizations for therapists based in that country.  Emails were sent to 1,038 psychotherapists and 889 psychiatrists.  As an incentive to participate in the email survey, participants were entered into a lottery to win a voucher worth approximately $200.  Three weeks after the initial emails were sent, a reminder email was sent thanking individuals who had participated and requesting further participation.  In total, only 25.7% (n = 495) of the therapists responded to the email and participated in the survey.  This is an obvious weakness that should be kept in mind as you consider the results.  The average age of the therapists who took part was 52, 53% were female, and they reported an average of 19 years of experience.  The therapists reported a wide range of theoretical orientations (e.g., 19% cognitive behavioral, 22% psychoanalysis, 11% depth psychotherapy, 18% systemic, 12% Rogerian, 5% gestalt).

I'll break down their findings by their relevance to the three stated purposes mentioned above.

Frequency of Use

The therapists in this study reported that they only use structured interviews with 14.8% of their patients.  Perhaps even more startling, 51.6% reported that they do not use structured interviews with any of their patients.  Surprisingly to me, psychologists and psychiatrists did not differ in the degree to which they used structured interviews.

View of Patients' Acceptance of Structured Interviews

The authors anticipated that therapists would expect patients to have much worse views of structured interviews than the patients would actually have.  To test this, they used the same measure utilized in the study described in the earlier PBB article (Suppiger et al., 2009) and directly compared the responses of the therapists in this study and the patients in the earlier study.  In the earlier study, the patients' global rating of satisfaction with the structured interview was 86.55 (out of 100).  In the current study, the therapists expected patients would report a global satisfaction rating of 49.41.  That is a HUGE discrepancy and it indicates that therapist fears about how patients will respond to structured interviews are not even particularly close to being accurate.

The global rating, while informative, does not tell the entire story.  On a specific item indicating that patients do not report everything that is bothering them in structured interviews, therapists exhibited significantly higher agreement than did the patients.  Given that patients have much more insight into the degree to which they are sharing what is on their mind than the therapists do (I'm sure some folks disagree with this, but the degree to which the opposing viewpoint violates the basic principles of science is difficult to overstate), this is a problem.  In a specific item indicating that patients feel "questioned out" by the end of a structured interview, again therapists exhibited significant more agreement with the idea than did the patients, who indicated that they did not feel exhausted or overburdened by the questions.  Additionally, patients reported that their relationship with the therapists was more positive and the interview was more helpful than the therapists believed they felt.  Overall, these results represent a fundamental disconnect between therapists and patients regarding the degree to which stuctured interviews are helpful, elicit enough information, and support a positive therapeutic relationship.

Why Therapists do not Use Structured Interviews

Perhaps the most stunning number presented in this study is that, even though 63% of the therapists agreed with the notion that structured interviews help them not overlook something, less than 15% use these tools.  The most commonly given reasons for not using structured interviews were "my clinical judgment is more useful to me" (37%...Paul Meehl weeps), "they take too long" (34%), and "they disturb the relationship to the patient (32%...and a direct contradiction of the data).

In terms of familiarity with administering structured interviews, 35% said "not at all/hardly," 42% said "a little," 17% said "quite well" and 6% said "very well."  As the authors of the study noted, these numbers reflect an impressive lack of training in and awareness of structured diagnostic interviews.

Taking things a step further, the therapists reported modest beliefs that the DSM-IV and/or ICD-10 diagnoses are helpful for their practice (1.69 out of 3), but much less belief that structured diagnostic interviews are helpful (0.99 out of 3).  In other words, they believed diagnoses may be modestly helpful (click here and here for arguments that they are, in fact, quite helpful), but did not believe structured interviews were a useful tool for making diagnostic decisions.

The final set of analyses run by the authors involved using therapist responses to predict the degree to which they utilize structured interviews.  What they found was that therapists who endorsed the following a less likely to use structured approaches:

• Clinical intuition is more valuable (again....*cringe*)
• Structured interviews disrupt the therapeutic relationship
• Lack of familiarity with structured interviews
• Patient will not respond positively to structured approaches

Now, to be fair, if a therapist believes these things, it makes functional sense that they would avoid structured approaches.  After all, what kind of health care provider would use an approach they believe could cause their client harm?  The issue here is thus the validity of those beliefs and the bottom line is that the data simply do not support any of the above mentioned notions (other than the lack of familiarity...which indicates a need for futher training by the therapists to ensure that they are well-versed in evidence-based approaches to health care).

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So what's the bottom line here?  Despite the strong evidence for enhanced validity and reliability through the use of structured approaches and the positive response of patients to such approaches, therapists typically favor unstructured interviews.  In a sense here, as is so often the case, the issue boils down to beliefs regarding the utility of science in health care and that's a debate that we at PBB take very seriously.  At the same time, these results undoubtedly reflect a sharp disconnect between how therapists perceive their clients' beliefs and what clients actually believe, which if you think about it, is a very impressive argument against the notion that the therapist's intuition is the surest path towards mental health. 

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If you would like to learn more about this or other topics discussed on PBB, we recommend that you consult our online store for scientifically-based psychological resources.

Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University

As a new approach, I am going to list the references from this article here instead of on the references page.  This may become my new standard approach:

Basco, M.R., Jeff, Q.B., Davies, D., Rush, A.J., Witte, B., Hendricks, W., & Barnett, V. (2000).  Methods to improve diagnostic accuracy in a community mental health setting.  American Journal of Psychiatry, 157, 1599-1605.

Bruchmuller, K., Margraf, J., Suppiger, A., & Schneider, S. (in press).  Popular or unpopular? Therapists' use of structured interviews an their estimation of patient acceptance.  Behavior Therapy.

Joiner, T.E., Pettit, J.W., Walker, R.L., Perez, M., & Cukrowicz, K.C. (2005).  Evidence-based assessment of depression in adults.  Psychological Assessment, 17, 267-277.

Suppiger, A., In-Albon, T., Hendriksen, S., Hermann, E., Margraf, J., & Schneider, S. (2009).  Acceptance of structured diagnostic interviews for mental disorders in clinical practice and research settings.  Behavior Therapy, 40, 272-279.

Zimmerman, M., & Mattia, J.I. (1999).  Psychiatric diagnosis in clinical practice: Is comorbidity being missed? Comprehensive Psychiatry, 40, 182-191.

Narcissistic personality disorder and DSM-V: Confusing alterations with elimination

by Michael D. Anestis, M.S.

I came across a fairly bizarre article in the Health section of the New York Times recently and feel compelled to comment on it here (click here to read the actual Times article).  Written by Charles Zanor, a psychologist in Massachusetts, the article discusses the pending alterations to the personality disorder section of the DSM in the upcoming DSM-V. 

As we detailed in an earlier post, the proposed changes in the DSM-V include a shift away from classic personality disorder diagnoses and towards an evidence-based profile approach in which individuals are scored on various levels of a variety of variables (click here to view the DSM-V page describing all changes to personality disorders).  Think of it this way: 

• Everybody has a certain level of certain variables (e.g., height, intelligence, age).  Rather than report a yes-no answer on whether or not we meet a certain level of one of these things (generally speaking), we tend to report specific levels (e.g., five feet tall, 110 IQ, 30 years old).  The new personality system will do the same, recording individuals' levels of a number of traits so as to provide an overall view of their global personality.

Why is this important here?  Well, first of all, people are making quite a fuss about the DSM "eliminating" diagnoses.  In this case, the uproar is about narcissistic personality disorder (NPD).  The thing is, it's not being eliminated.  If you look at the list of personality traits that will be assessed in clients, you'll see one entitled antagonism, which is defined by the committe as:

"Exhibits diverse manifestations of antipathy towards others, and a correspondingly exaggerated sense of self-importance."

Taking it a step further, each personality trait includes a list of trait facets to be considered.  Listed amongst those for antipathy is...wait for it.....NARCISSISM.

That's right, every client should, in theory, be rated on their level of narcissism.  In this sense, not only is narcissism not being eliminated from our assessment of personality, it is being included in a profile system that, in theory, will be utilized in assessments of all clients, thereby INCREASING the likelihood clinicians will assess this construct.

Now, I realize that this is still a marked change from the current diagnostic system, but the thing is, there is essentially no empirical evidence demonstrating that the diagnosis of NPD is a valid and reliable idea (which is the reason it is being massively altered) and there is not a single evidence-based treatment for NPD.  Massive changes to an idea that has no evidence supporting that it exists in exactly the way it is described (e.g., number of symptoms required) and for which we have no effective treatments does not seem like a horrific idea to me.

In the article, Dr.Gunderson refers to these changes as "draconian," citing the fact that such a massive amount of change within one diagnostic area has never before been done.  The fact that it is being done for the first time, however, does not qualify it as draconian.  If it flew in the face of empirical evidence, that would make more sense to me, but it does nothing of the sort.  Using this same logic, the decision to make DSM-III based upon observable behaviors instead of psychodynamic principles would also be viewed as draconian and there aren't many people trumpeting that idea.  The issue here is the accuracy of the changes, not the scope of the changes.

The final aspect of this article that caught my attention and to which I feel compelled to reply is Dr.Shedler's comment that the committe is made up predominantly of researchers who do little clinical work. 

• Question #1: on what basis is this claim made (e.g., how many patient hours were accumulated by each committe member?)?  
• Question #2: what evidence is there that somebody with a greater level of clinical activity (should his assumption be correct) make more valid decisions regarding diagnostic criteria?

I completely understand folks having reservations about these changes.  I certainly have some and I have voiced them in a number of forums (e.g., the DSM-V website, the online forum of Personality Disorders: Theory, Research, and Treatment).  That being said, it is important that, when we voice these concerns, we ensure that they actually reflect reality.  If not, things like this happen: misinformation spreads in an internationally renown forum and folks argue about something that is not even happening.

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If you want to learn more about this or other topics discussed on PBB, we recommend that you consult our online store for scientifically-based psychological resources.

Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University

Deflating empty arguments - A defense of mental illness diagnoses

by Michael D. Anestis, M.S.

Welcome back to PBB.  It's been a chaotic couple of weeks for us and the site will be making a transition of sorts as Joye takes the lead and I begin my internship.  I'm not done writing by any means, but my posts will be much less regular for a while.

I had several topics ready for tonight's post, but everything changed when my colleague - Kelly Caron - pointed me towards this mind-boggling article written on the Huffington Post by a psychiatrist named Peter Breggin (click here to read the article).  In the article, Breggin attempts to make the case that mental illness diagnoses are harmful and based on nothing but opinion (an ironic criticism given that he bases this on his opinion).  As you might guess, I disagree wholeheartedly with his conclusions.

As I have done in the past, I will paste a comment from the original article in italics and then write my retort below it.

"In reality, psychiatric diagnosing is a kind of spiritual profiling that can destroy lives and frequently does."

I'm not even certain I understand what "spiritual profiling" means, but it certainly sounds awful.  My assumption is that Breggin is claiming that a mental illness diagnosis is a criticism of an individual's character, a critique of who they are as an individual.  This is completely untrue.  A mental illness diagnosis is a recognition that an individual is experiencing a group of systems that often cluster together and which have been shown to respond to a particular treatment or set of treatments, some of which are pharmacological and some of which are psychosocial.  No therapist should imply that a diagnosis is some sort of character flaw or a description of the sum of an individual's personality.  If they do, the problem is with the therapist, not the diagnosis.

"First, there's the obvious cookie cutter problem. People can't be easily fit into the prefabricated labels contained in the Diagnostic and Statistical Manual of Mental Disorders from whence all official diagnoses emanate. Diagnoses frequently change, often in an effort to justify this or that drug. It's not realistic, enlightening or empowering to reduce yourself or your child to one of these diagnoses. Psychiatric diagnoses are simplistic."

If Dr.Breggin's point is that diagnoses are imperfect, he's spot on.  This does not seem to be his point, however.  He seems to be saying that the diagnostic categories never properly fit individuals' presenting problems.  On what does he base this claim?  Again, nobody is saying that panic disorder, depression, borderline personality disorder, or any other diagnosis explains the depths of an individual's soul.  They are simply saying that individuals often present with a particular cluster of symptoms and that research has enabled us to learn a lot about those symptoms and how to treat them.  Sometimes, an individual meets criteria for more than one diagnosis (in fact, this is the norm).  Sometimes, an individual's symptoms do not fit the criteria well but still cause significant impairment and/or distress.  Those individuals receive a "not otherwise specified" diagnosis and are still eligible for treatment.  As time goes by, diagnoses are adjusted.  These changes are not made to justify this or that drug, but rather to fit what we have learned through research since the previous edition of the DSM was published.  This is, in fact, the very nature of science: imperfections are gradually clarified through research, then changes are made to the model in order to better reflect current knowledge.  Would it be nice if we understood diagnoses perfectly?  Absolutely.  This is, of course, true of all scientific fields, however, so if we are going to disown this component, we must do so to all (including medical diagnoses, which also change to reflect increased knowledge).

"Consider this: Psychiatric diagnoses are always negative. There are no such diagnoses as "Exceptionally Able to Face Stress" or "Remarkably Resilient" or "Courageously Independent in the Face of Abuse." That's how I like to think about the people that I try to help--as heroes or potential heroes in their own life stories. I never want them to sum up, categorize or symbolize their lives in such a demeaning fashion as a psychiatric diagnosis.

But that's only the beginning of the problem. These diagnoses imply that you or your children have a disease, especially an underlying biochemical imbalance. This can be discouraging and disempowering. Having a psychiatric diagnosis tends to make us feel helpless to transform our lives or the lives of our children for the better. It makes us feel less responsible for our own psychological and spiritual recovery and for that of our young and dependent children.

Medical diagnoses are real. When you learn you have pneumonia, diabetes or even cancer, you quickly discover that there are potential remedies. There are scientific tests and studies to diagnose the disease and to evaluate its treatment. Medical diagnoses don't demean your mind and your soul, they describe your bodily impairments."

There are a number of troubling contradictions here.  First of all, while Breggin is correct in noting that there are no mental illness diagnoses that are positive like "remarkably resilient," there are also no medical diagnoses that are positive (e.g., "super special not broken bone!").  If this is a problem for mental illness, why is it not a problem for medical illnesses?  People come in for the treatment of problems and effective clinicians recognize those problems, use science to help them identify the best treatment, and then also utilize the client's strengths in that treatment.  Providing a diagnosis of a mental illness does not prevent a therapist from working with and advertising a client's strengths.

Going a bit further here, mental illness diagnoses are not negative in nature. People are not being labeled - their symptoms are being described.  It is the job of the therapist to describe symptoms as symptoms and not as an individual's identity.  When this is done properly, data has demonstrated convincingly that clients actually respond positively.  Don't believe me?  Click here to read Dr.Jill Holm-Denoma's description of data that verifies my claim.

In the above segment, Breggin simultaneously claimed that psychiatric diagnoses are demoralizing because they imply that we have a disease or chemical imbalance (which they don't) and that medical illnesses - which include diseases and chemical imbalances - don't demean us because they describe bodily impairments.  So...mental illnesses are bad because they sound like diseases but diseases are good because they are only about our bodies.  That's not strong logic.

Breggin also noted that when you are diagnosed with a physical ailment, you feel encouraged because you can immediately learn about potential remedies through objective tests and science.  Well...when you are diagnosed with a mental illness, you can also learn about the multitude of empirically supported treatments that are available (which includes a vast array of psychosocial treatments not mentioned in Breggin's article).  Breggin is correct in noting that there is an element of error inherent in psychosocial diagnostic tools; however, there is also extensive research supporting the reliability and validity of a number of diagnostic tools, including structured diagnostic interviews and a variety of behavioral observations.  On the medical side, consider that some diagnoses are fatal, meaning there are no treatments available, some treatments are so expensive that they will bankrupt a family and ruin them financially, and some rely on diagnostic tools that heavily weigh subjective interpretations or indirect measures of the actual ailment.  Psychological diagnostics are not as sloppy (when properly utilized) as Dr.Breggin believes and medical diagnostics (when properly conducted) are not as full proof as Dr.Breggin believes.

"Psychiatric diagnoses take power and authority over your life, and the lives of your children, out of your hands. They place that power and authority in the hands of health professionals. Often it takes but a few minutes in an office to transform you or your child from a complex human being into a product on the psychiatric assembly line--and endless assembly line that can lead to a ruinous lifetime.

Perhaps worst of all, these diagnoses almost inevitably lead to the prescription of psychiatric medication to you or your child."

If you ever encounter a clinician who makes you feel this way, immediately go to another clinician - one that utilizes empirically supported treatments and proper diagnostic procedures.  When psychiatric diagnoses take over an individual's life, something has gone horribly awry in the diagnostic process and the problem lies with the therapist, not the concept of diagnostics.

Also, diagnoses do not almost inevitably lead to the prescription of psychiatric medication.  Click here to read all of our articles on empirically supported psychosocial treatments for mental illness.  I'll let that data speak for itself.

"But something more subtle occurs when we accept a psychiatric diagnosis for ourselves or a loved one. We lose empathy for ourselves and our loved one. Instead of learning about and identifying with the sources of our emotional pain and suffering, and our failures in life, we ignore our real lives and explain ourselves away with the diagnosis. To understand ourselves or anyone else, to help ourselves or anyone else, we must care about the details of the life before us."

What?  There is absolutely no logic to this argument.  None.  Empathy does not disappear when we accept the diagnosis of mental illnesses unless we have a completely distorted understanding of mental illness.  Surely Dr.Breggin knows this and got carried away with his prose.

"The destructiveness of psychiatric diagnoses could fill a book. You and your loved ones, and those you seek to help can never be understood though a psychiatric diagnosis. Psychiatric diagnosis is like looking at the world through wrong end of a spiritual telescope. Instead you have to open your heart and your mind to knowing what you have endured, and the mistakes you have made, and the right choices you have made, and the good things you have done that have led you to this moment in your life. You must be ready to appreciate your life and the life of anyone you seek to help."

The destructiveness of ignorance and empty rhetoric could fill a much larger book and that book would actually be accurate.  Dr.Breggin is right in saying that an individual can not be understood through a diagnosis of a mental illness.  You know what can be understood that way though?  Mental illness.  The point here is that mental illnesses are not who we are and any clinician who attempts to understand the entirety of a person through a mental illness diagnosis is as idiotic as a clinician who attempts to understand the entirety of a person through a diagnosis of a broken leg.  Mental illnesses are not who we are - they are what we are struggling with.  Identifying those mental illnesses helps us know which treatments to use and to understand that we are not weak, weird, or alone, but rather completely human and experiencing common emotional processes that, left untreated, often linger and become more severe.  When an individual receives a mental illness diagnosis, their strengths and experiences are not pushed out of the picture.  Those variables can absolutely be assets in treatment.  Their existence, however, does not invalidate the mental illness.

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I'm sure that Dr.Breggin has pure intentions and that he is wholly devoted to helping individuals improve their lives.  Even still, his words are disturbing and have the potential to do harm as they steer people away from proper treatments and perpetuate myths about mental illness.  It angers me to no end when individuals write harmful an factually incorrect information about mental illness - particularly when those individuals are educated enough that they should have a clear grasp on the scientific evidence that completely contradicts their point.

If you are experiencing symptoms of a mental illness, please seek help.  Click on our "EST Clinics" link or call a university in your local area and ask if they utilize evidence-based treatments.  If you have a bad experience with an individual who utilizes such approaches, try another therapist before you give up on the process.  Additionally, 1-800-273-TALK is always available if you are in a crisis.

If you would like to learn more about the topics discussed on Psychotherapy Brown Bag, please consult our online store for scientifically-based psychological resources.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University and a resident at the University of Mississippi Medical Center

Schizoid personality disorder: Does it truly qualify as a mental illness?

by Michael D. Anestis, M.S.

In the early weeks of each semester, as I am teaching Abnormal Psychology to undergraduates, I almost invariably encounter at least one student who raises concerns that our system of classifying mental illnesses simply places labels on people for being different.  This is, of course, an important question to consider.  After all, if our helping profession is simply placing scarlet letters on people who are different from the norm, we would not be accomplishing anything remotely similar to our purpose.  I assure each student, however, that this is not the case for a number of reasons.  First of all, mental illnesses are required to not only represent a difference from the norm, but also a source of distress and/or impairment.  In other words, due to the symptoms that comprise the diagnosis, the individual is chronically upset and/or unable to function effectively in his or her life.  If the individual is not experiencing distress and/or impairment as a result of the symptoms, a diagnosis is not warranted.  Additionally, I point out, diagnoses serve an important clinical and scientific function, as they allow us to ensure that we are all discussing the same concept when we study and treat clients.  In other words, diagnoses are not labels intended to merely classify people into groups, but rather a method by which we can ensure that everyone has the same understanding of the manner in which symptoms cluster together and through which we can develop databases of information on the course, severity, and effective treatment for particular constellations of symptoms.  Much like specifying the type and nature of cancer is intended to inform treatment rather than to simply label an individual a particular type of cancer patient, mental illness diagnoses are used to perform a function that has nothing to do with simply declaring an individual to be different.

All that being said, there is one disorder covered in my course each semester that always leaves both my students and me a bit concerned that the DSM is forgetting its own definition of mental illness: schizoid personality disorder (SZD).  SZD is included in the Cluster A personality disorders, which are theorized to be a part of the schizophrenia spectrum, although the relationship between SZD and schizophrenia is supposedly weaker than the relationship between schizotypal personality disorder and schizophrenia.  The DSM-IV-TR defines SZD as follows (p.697)

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(A) A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

• Neither desires nor enjoys close relationships, including being part of a family
• Almost always chooses solitary activities
• Has little, if any, interest in having sexual experiences with another person
• Takes pleasure in few, in any, activities
• Lacks close friends or confidants other than first-degree relatives
• Appears indifferent to the praise or criticisms of others
• Shows emotional coldness, detachment, or flattened affectivity

(B) Does no occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder, or a pervasive developmental disorder and is not due to the direct physiological effects of a general medical condition

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So, according to the DSM, individuals with SZD are characterized by a lack of interest in maintaining close relationships with others.  They are not anxious about interacting with other people or concerned that they will not be accepted - such symptoms are more closely associated with social anxiety disorder, avoidant personality disorder, and paranoid personality disorder.  Additionally, they are not theorized to lack the ability to interpret the non-verbal communications of others and thereby hindered in social interactions, a trait better associated with autism spectrum disorders.  They simply do not have any interest in relating to other people.  Keep in mind, there is also no evidence that these individuals experience elevated rates of depression as a result of social isolation.

When I think about this disorder, I have a hard time understanding it.  After all, who can imagine a life in which we simply do not have any interest in close connections with other people unless we are already depressed or are fearful of others' perceptions of us?  An important point to consider, however, is that living in a manner that is difficult to understand or relate to is not grounds for a diagnosis of a mental illness.  Personally, I have a similarly difficult time understanding how anyone could live without Pittsburgh sports teams, television, or Kraft macaroni and cheese (forgive me on that last one), but I do not think that individuals who lack interest in these valued resources are mentally ill.  Certainly interpersonal relationships are a more pivotal aspect of most individuals' lives and a key component of the evolution and continued existence of our species, but this again does not necessarily speak to the idea of distress and/or impairment.

You may have noticed the complete lack of citations mentioned thus far in this article.  This is not due to a lack of interest in the research on my part, but rather a complete dearth of data on this disorder.  A quick search for "schizoid personality disorder" or simply "schizoid" will result in a multitude of articles in psychoanalytic journals, none of which include empirical studies.  Instead, these are case descriptions of theories based upon psychoanalytic principles rather than an objective evaluation of data accumulated through scientifically sound experiments or epidemiological studies.  We know so little about this disorder that the DSM lists its prevalence as "uncommon in clinical settings." That's right...they couldn't even provide a range of numbers because so little is known on the matter.  In 2004, Bridget Grant and colleagues published a study in the Journal of Clinical Psychiatry that reported on rates of specific personality disorders in the general population in the United States.  That study indicated that 3.13% of Americans meet criteria for SZD, although that number has not been replicated elsewhere.

Considering all of this information, all we know about this disorder is that it appears to be relatively rare, at least in help-seeking populations, and that it is characterized by a lack of interest in a component of life that is typically indispensable to others.  Given that no studies have linked SZD to elevated rates of depression, anxiety, suicide, or any other maladaptive outcome, however, it remains unclear why this is considered a personality disorder rather than a personality type.  What would the goal of treatment be - to make individuals with SZD be interested in interpersonal relationships?  Is therapy to change somebody's interests if those interests do not cause distress and/or impairment even ethical and, if it is, is it feasible?  Certainly, SZD is theorized to be associated with schizophrenia, but striving for difficult to attain goals is associated with anorexia nervosa and we do not diagnose "ambitious personality disorder."  Only when ambitions cause distress and/or impairment are they seen as problematic.

I'm curious to hear what readers think about this situation. What do you think about this diagnosis?  Is it reasonable to keep this in the DSM or does it need to be altered in a particular manner in order to ensure that it truly qualifies as a mental illness?

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If you would like to learn more about this or other topics discussed on PBB, we recommend that you consult our online store of scientifically-based psychological resources.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Looking east: Do Chinese adolescents experience borderline personality disorder?

by Michael D. Anestis, M.S.

If any of you listened to last week's episode of "Science Friday" on NPR, which featured Richard McFall, Bruce Wampold, and Dianne Chambless discussing the importance of science in clinical psychology, you likely heard a caller towards the end of the show raise a very important point.  A significant problem, she said, is that much - although by no means all - of our research on psychopathology and psychotherapy has been conducted on predominantly Western Caucasian samples of at least moderate socioeconomic status.  This, of course, raises questions regarding the degree to which what we know about mental illness applies to other cultures and populations.

Without question, there are several wonderful exceptions to this problematic situation and today I would like to discuss a newly published example.  In this study, published in the Journal of Personality Disorders by See-wai Leung and Freedom Leung (2009), the authors examined the degree to which the concept of borderline personality disorder (BPD) exists in Chinese adolescents in the same form it is found in the United States and, if so, how common the disorder might be in that population.  To justify their efforts to examine these questions, Leung and Leung (2009) provided a thorough background on the current situation.  Approximately 1-2% of the general population in Western world meets criteria for BPD (Torgersen, Kringlen, & Cramer, 2001).  The DSM-IV-TR indicates that the diagnosis can be applied to adolescents; however, many researchers and clinicians argue that this should not be the case because adolescence is a time of change and many of the symptoms of BPD (e.g., identity disturbance, rapidly shifting emotions) are actually quite normative during this period of development.

The debate about whether or not to apply BPD diagnoses is an interesting one and those against such diagnostic decisions can turn to some fairly compelling data to support their case.  Specifically, Bernstein and colleagues (1993) found that less than 30% of the adolescents who initially met criteria for BPD in their sample still met those criteria two years later and not because they were typically receiving effective treatment.  Given that personality disorders are theorized to be fairly stable, this presents a bit of a problem.  At the same time, other researchers have explained these findings in an interesting way.  For example, Meijer, Goedhart, and Treffers (1998) pointed out that, while the diagnosis itself might not be particularly stable across time, certain characteristics of the disorder are.  Put simply, some symptoms such as non-suicidal self-injury (NSSI), suicidal behaviors, and dissociation might fluctuate over time, becoming more and less common at different points, whereas other symptoms, such as unstable moods and difficulty controlling anger might be more stable.  In fact, in their sample, while only 30% of individuals who demonstrated the former set of symptoms initially did so again at follow-up, 70% of individuals who demonstrated unstable moods and under-controlled anger did so at follow-up.  If you remember our discussion of the possibility of a dimensional model of personality disorders in DSM-V, this might make a lot of sense to you, as such models suggest that we all might have varying amounts of particular symptoms at a given moment.  So, while some personality characteristics might be rather stable and represent a vulnerability to an outcome (e.g., a diagnosis of BPD), some personality characteristics and behaviors might not be quite so stable and may disappear altogether at times or simply become less prominent (thereby influencing diagnostic status).

Lueng and Lueng (2009) looked at these findings as well as a number of factor analyses of BPD in adolescents and concluded that, while there is room for discussion on particulars of the issue, the concept of BPD in adolescents appears to be valid.  How common BPD is in adolescence, on the other hand, is less clear, as studies that have aimed to determine that have been highly flawed.

All of the information we've discussed so far has centered on Western populations.  The authors of this study, however, were interested in examining these questions in Chinese adolescents.  Currently, BPD is not a part of the mental health diagnostic system of China (Chinese Classification of Mental Disorders - III; Chinese Psychiatry Association, 2001).  Psychologists in China argue that the concept of BPD is overly vague and that particular components, such as a fear of abandonment, are not culturally appropriate in that context.  These points, however, represent empirical questions, the type of question better answered through systematic studies than through discussions amongst committee members, particularly given the mountains of evidence for the existence of the syndrome in other parts of the world.  Importantly, Lueng and Lueng (2009) pointed out, if BPD exists in China with prevalence rates comparable to that of the West, that means that there are 13 to 26 million Chinese suffering from these symptoms without being properly diagnosed and treated.  It goes without saying that this would be an unacceptable situation, particularly given that a strong empirically supported treatment - dialectical behavior therapy (DBT) - exists for this diagnosis.

The authors spent a lot of time discussing various models of BPD that, quite frankly, would be difficult to describe on PBB without relying upon a lot of complicated jargon.  That being said, if you are interested in reading about the factor structure of BPD in detail, I recommend reading the full article and/or contacting me for more details.  Here, I'll focus on some of the more straight forward results.  First, however, let's discuss how the study was conducted.  At Time 1, 5,224 adolescents between the ages of 12 and 20 filled out a series of questionnaires.  One year later, at Time 2, 5,461 adolescents filled out those same questionnaires.  4,110 individuals were assessed at both time points and the vast majority of those who only took part in Time 1 did so because they graduated and were no longer available.  Due to strong encouragement by school administrators, nearly 99% of eligible students participated in the study.

Lueng and Lueng (2009) were hoping to conduct structured diagnostic interviews on each participant; however, the schools demanded complete anonymity in the study and such procedures were ruled out.  As a result, diagnoses of BPD were determined through two alternative methods.  The first was through a cut-off point on a self-report measure of BPD.  The second was through a method developed specifically for this study.  The authors selected three self-report questions from the questionnaires that represented each symptom and only gave a diagnosis if a participant endorsed all three items for at least five BPD symptoms (an attempt to mirror the DSM requirements).  Neither of these approaches is ideal.

The authors' findings were very interesting...and highly supportive of the idea that BPD not only exists in Chinese adolescents, but exists in the same form as found in the West.  Again, the details of the factor structure of BPD in Chinese adolescents is a topic that requires a closer reading of the original document, but to summarize those findings, the authors demonstrated that the symptoms that tend to cluster together in the US clustered together in the same way in this Chinese sample.  In other words, the grouping of BPD symptoms does not appear to simply reflect a Western bias.  Chinese adolescents were just as likely to display a syndrome defined by unstable emotions, impulsive behaviors, disturbances in self-image, and chaotic interpersonal relationships.

The next question, however, is how common these symptoms are in this population.  The answer, not surprisingly, depended upon the method used for determining diagnoses.  Using the simple cut-off score mentioned above, 7.7% of females and 5.0% of males met criteria for BPD.  These numbers clearly represent a greater vulnerability in females and are substantially higher than the rate in the general population in the West (although remember, that Western rate is not specific to adolescents).  When the more stringent method mentioned above was used, only 2.2% of females and 1.8% of males met criteria for BPD.  Using this approach, sex differences disappeared and the prevalence rates became similar to those found in the West.  So, BPD appears to be at least as common in Chinese adolescents as it is in the West.

Before wrapping up their study, Lueng and Lueng (2009) looked at one last question: how stable are BPD features in Chinese adolescents?  Using the simplest way of testing this question - looking at the correlation between overall symptoms at Time 1 and Time 2 - the results indicated that BPD was fairly stable (r = .60 for females and .51 for males; p < .001).  Looking at diagnoses with the cut-off score, however, the picture was different.  Only 36.8% of females and 36.2% of males who met BPD criteria at Time 1 also met those criteria at Time 2.  This result looks very similar to those of Bernstein and colleagues (1993) that I mentioned earlier.  Much like the Meijer et al (1998) findings I mentioned above told us, however, there is more to that picture.  Specifically, certain symptoms - particularly paranoid thoughts and unstable moods - were highly stable, whereas others - particularly impulsive behaviors, fear of abandonment, NSSI, and suicidal behaviors - were more likely to come and go between time points.  So, the overall picture is that symptoms in general are fairly stable, but some symptoms are more stable than others, which means that meeting criteria for the diagnosis of BPD at one point is no guarantee that the same will be true a year later.

I was very excited when I found this study.  The topic is inherently interesting to me and research like this is incredibly valuable, as it helps us to get a better sense of whether or not what we study in the US applies to the rest of the world.  Obviously, this is only one study and it is not without its imperfections, but it was nonetheless incredibly informative.  If BPD truly is as common in China as it is in the West, that means there are tens of millions of people in that country who are not receiving adequate care for a disorder marked by a highly elevated suicide rate and who likely have little understanding about why such symptoms cluster together and impact their lives as they do.  Given that BPD is not a part of the Chinese diagnostic system, it seems highly unlikely that a substantial proportion of Chinese therapists are trained in DBT, which means that even if the diagnostic system were updated to reflect these data, help would not be readily available.  Studies like this shine a light on areas of weakness and hopefully can serve as the first step in a chain reaction of changes that ultimately result in the greater proliferation of accurate information, the development of more efficient and effective diagnostic approaches, and the implementation of a system of mental health care that adequately addresses the needs of consumers.

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If you would like to learn more about borderline personality disorder and dialectical behavior therapy, we recommend the following items, each of which can be found in our online store for scientifically-based psychological resources:

• Skills Training Manual for Treating Borderline Personality Disorder by Marsha Linehan

• Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha Linehan
  

• Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings by Linda Dimeff and Kelly Koerner

• Dialectical Behavior Therapy with Suicidal Adolescents by Alec Miller, Jill Rathus, and Marsha Linehan

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Eating disorders and DSM-V

by Michael D. Anestis, M.S.

I hope everyone enjoyed their Thanksgiving holiday.  We certainly enjoyed our time off, but are excited to return to PBB.  Given the amount of time I spent thinking about food during this past week, with mashed potatoes playing a particularly prominent role in my thoughts, I figured it might make sense to keep food at the center of today's discussion.

In the current issue of the International Journal of Eating Disorders, a number of prominent researchers published articles discussing proposed changes for eating disorder diagnoses in the upcoming DSM-V.  Several articles discussed the potential inclusion of binge eating disorder in the main text of the DSM (it is currently listed as a disorder in need of further research and results in a diagnosis of eating disorder not otherwise specified) and the addition of purging disorder and night eating syndrome as well.  The article that interested me the most, however, was written by Timothy Walsh and Robyn Sysko (2009) of Columbia University and discussed a proposed overhaul of the eating disorder diagnostic system for DSM-V.

Before explaining their proposed system, Walsh and Sysko (2009) took care to explain why they believe such changes are necessary.  As it stands, the DSM formally recognizes two eating disorder diagnoses: bulimia nervosa (BN) and anorexia nervosa (AN).  As I mentioned above, binge eating disorder (BED) is listed in the appendix as a disorder in need of further research, so no formal BED diagnoses exists.  Instead, individuals who meet criteria for BED receive a diagnosis of eating disorder not otherwise specified (EDNOS).  At first glance, this might not seem all that problematic, but there are a number of other issues that clarify why this needs to be addressed.  Research has demonstrated that between 50% and 70% of eating disorder diagnoses are EDNOS (Ricca et al., 2001; Turner & Bryant Waugh, 2004).  In other words, the majority of individuals with an eating disorder do not meet criteria for one of the two eating disorders recognized by the DSM.  As such, the catch-all residual category of EDNOS accounts for an absurdly large proportion of patients.

The problems of EDNOS are not limited to the fact that it accounts for such a high percentage of eating disorder diagnoses, however.  Perhaps even more problematic than that is the fact that the category itself is so broad.  Walsh and Sysko (2009) pointed out that a 14-year-old girl who meets all of the criteria for AN except that she reports menstrual activity and a 46-year-old man with BED would both be given a diagnosis of EDNOS despite the fact that these two individuals have very little in common.  In other words, knowing that somebody has EDNOS tells us very little about who they are and what symptoms are causing them distress and/or impairment and yet this diagnosis is nonetheless what we are most likely to see listed in the case file for a patient with an eating disorder diagnosis.

Walsh and Sysko (2009) were thus determined to develop a diagnostic system for eating disorders that would result in substantially fewer individuals being given an EDNOS diagnosis but which would not reduce the validity of the diagnoses or cause a disconnect between current research and the new diagnoses.  Their proposed model, which they named the Broad Categories for the Diagnosis of Eating Disorders (BCD-ED) involves three hierarchical categories mirroring the current most researched eating disorder diagnoses and also retains a much more limited EDNOS category.  They defined the categories as follows (pg.755):

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Anorexia Nervosa and Behaviorally Similar Disorders (AN-BSD)

"An eating disorder category characterized by the restriction of food intake relative to caloric requirements resulting in the maintenance of an inappropriately low weight, not better explained by a general medical condition or another psychiatric disorder.  The prototype for this category is an individual meeting DSM-IV criteria for AN."

Bulimia Nervosa and Behaviorally Similar Disorders (BN-BSD)

"An eating disorder category characterized by recurrent out of control eating and the recurrent use of inappropriate purging methods to control eating or weight.  The prototype for this category is an individual meeting DSM-IV criteria for BN."

Binge Eating Disorder and Behaviorally Similar Disorders (BED-BSD)

"An eating disorder characterized by recurrent episodes of out of control eating.  The prototype for this category is an individual meeting DSM-IV criteria for BED."

Eating Disorder Not Otherwise Specified (EDNOS)

"A residual diagnostic category for all other individuals with a clinically significant eating disorder."

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So, Walsh and Sysko's (2009) model essentially involves shifting BED from the appendix to the main text of the DSM and including sub-threshold patients in the broader eating disorder categories rather than giving them an EDNOS diagnosis.  In other words, an individual meeting all the criteria for AN except that she reports menstrual activity would now receive an AN-BSD diagnosis instead of EDNOS and an individual who frequently binge eats and purges, but averages less than twice per week would receive a diagnosis of BN-BSD rather than EDNOS.

Without question, this would result in a smaller proportion of eating disorder patients receiving EDNOS diagnoses, but the authors acknowledged two other issues that require attention.  First, does the hierarchical structure of their model make sense?  And second, would this shift result in an over-diagnosis of eating disorders because it is so broad?

The first question, which essentially asks whether AN is more severe than BN and whether BN is more severe than BED, is difficult to answer.  For one thing, the authors could find not studies that specifically addressed that particular question.  Secondly, it would be difficult to determine the relative danger of mild AN compared to severe BN, particularly if we are not also considering comorbid diagnoses, prior history of suicidal behavior, and prior responses to treatments.  The authors openly admitted that this is a bit of a blurry issue; however, they also provided some evidence supporting their decision to structure the model in this manner.  For one thing, of all the eating disorder classifications, AN involves the highest mortality (Hoek, 2006) and medical complication (Mitchell & Crow, 2006) rates and also the poorest treatment response and greatest rate of relapse.  The picture is a bit less clear with respect to BN and BED, with some studies indicating that BN is more severe with respect to prognosis (Fairburn, Cooper, Doll, Norman, & O'Connor, 2000; Hay & Fairburn, 1998) and others not supporting any difference between the categories (Fitcher Quadfleig, & Hedlund, 2008).  So, support for listing AN-BSD as the most severe is fairly strong, but support for the hierarchical structure of BN-BSD and BED-BSD is less compelling.

The second question - whether this new system would result in the over-diagnosis of eating disorders - is equally difficult to answer, as there is no way to conclusively predict the future.  On the one hand, the broad nature of the categories might cause some clinicians to give a diagnosis they otherwise might not give.  On the other hand, these new categories do not seem any more broad than the standard EDNOS diagnosis, so I am not certain I see any reason to believe there would be a sudden surge in diagnoses unless clinicians are simply wary of diagnosing EDNOS but somehow more willing to provide an questionable diagnosis of another eating disorder (and there are no data I am aware of that indicate this is the case).  Regardless, Walsh and Sysko (2009) proposed that, in an effort to prevent over-diagnosis, the DSM-V should include specific criteria requiring functional impairment as a direct result of disordered eating.  In other words, the DSM-V should be clear about what constitutes clinically significant distress and/or impairment so as to help clinicians determine if a particular patient warrants a diagnosis (e.g., does the client exhibit an "inappropriately low" weight?  Does the client binge eat often enough?).

On the whole, I think that this model is imperfect, but a great idea.  Reducing the reliance upon EDNOS is an important goal for DSM-V.  I do, however, have a couple of concerns that went unaddressed in the Walsh and Sysko (2009) article.  First, in their definition of BN-BSD, they mentioned that the client must exhibit "purging" behaviors whereas DSM-IV requires "inappropriate compensatory behaviors."  Purging involves attempts to immediately expel what was previously consumed (e.g., self-induced vomiting, the use of laxatives) whereas the broader category of compensatory behaviors can include non-purging behaviors aimed at weight control such as excessive exercising and fasting.  Does the Walsh and Sysko (2009) model thus require a reclassification of some individuals who would otherwise meet criteria for BN and, if so, is such a change justified (e.g., do individuals with purging versus non-purging BN respond differently to different treatments?)?  Additionally, the new model does not address the issue of purging disorder.  Night eating syndrome seems likely to end up in the BED-BSD category, but purging disorder seems likely to still result in an EDNOS diagnosis.  It might be that Walsh and Sysko (2009) want to see more research conducted on purging disorder before it is added so definitively to an eating disorder diagnostic scheme, but I would have liked to see them discuss that issue in order to clarify the point.

In the other DSM-V models we have discussed on PBB (mood and anxiety disorders, personality disorders, PTSD, autism spectrum disorders), the proposed changes have been fairly radical in nature.  The eating disorders proposal, on the other hand, is fairly conservative.  Walsh and Sysko (2009) did an admirable job of proposing a system that would reduce reliance upon the EDNOS diagnosis and cluster similar behaviors with one another.  That being said, do you see any strengths and/or weaknesses that went unaddressed in this discussion?  Do you have a suggestion for an alternative model?  Do you think changes to the system are even necessary in the first place?  We look forward to hearing your thoughts.

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If you would like to learn more about eating disorders and their treatment, we recommend the following items, all of which are available through our online store of scientifically-based psychological resources:

• Cognitive Behavior Therapy and Eating Disorders by Christopher Fairburn

• Overcoming Binge Eating by Christopher Fairburn
  

• If Your Adolescent Has an Eating Disorder: An Essential Resource for Parents by Timothy Walsh
  

• Treatment Manual for Anorexia Nervosa: A Family-Based Approach by James Lock, Daniel le Grange, Stewart Agras, and Christopher Dare
  

• Eating with Your Anorexic: How My Child Recovered Through Family-Based Treatment and Yours Can Too by Laura Collins
  

• Dialectical Behavior Therapy for Binge Eating and Bulimia by Debra Safer, Christy Telch, and Eunice Chen
  

• Eating Disorders by Pam Keel

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

The fate of Asperger's syndrome in DSM-V: A follow-up to last week's article

by Michael D. Anestis, M.S.

Last week, I wrote an article discussing some of the proposed changes to the autism spectrum in the upcoming DSM-V.  The article was based upon a review in the New York Times (NYT) - an unusual inspiration for a PBB article, but one that seemed worthwhile given the quality of the NYT piece.  Of the proposed changes, the most monumental and controversial is the potential for shifting the diagnoses of Asperger's syndrome and pervasive developmental disorder not otherwise specified (PDD-NOS) into a single autism spectrum disorder diagnosis in response to evidence indicating that there are no qualitative differences between these disorders and autism proper. The comments readers left on the article were fascinating and I was already considering a follow-up when, this morning, I came across an editorial - again in the NYT - written by Simon Baron-Cohen of the Autism Research Center at Cambridge University.  Dr.Baron-Cohen weighed in on this same issue and detailed why he believes that this decision would be premature and potentially harmful and I wholeheartedly urge you to read his well-written commentary (link).

I wanted to touch on this topic again today for a number of reasons.  First, I wanted to provide a resource written by an expert on the field that provides a more cautious opinion of the matter than was presented in the original NYT piece and the PBB article that I wrote.  Doing so provides more balance in the evidence.  Additionally, I wanted to respond to a couple of points written by Dr. Baron-Cohen with which I do not entirely agree (or disagree).  Before doing any of this, however, let me provide you with a brief overview of the author.  Dr.Baron Cohen is an extremely prolific researcher on this topic.  In fact, a quick PsycInfo search revealed 210 publications in peer reviewed journals.  To put it mildly, that is incredibly impressive.  The sheer number of publications, however, does not do justice to the quality.  Recent published works on which he has contributed have provided impressive insight into basic physiological differences that define the autism spectrum.  For instance, one study demonstrated that individuals with autism spectrum conditions (ASC) exhibited enhanced visual acuity relative to individuals without ACS's and that this enhanced acuity lies in the region of birds of prey (Ashwin, Ashwin, Rhydderch, Howells, & Baron-Cohen, 2009).  This, of course, lends empirical evidence to the general belief in a hypersensitivity to sensory stimuli in ASC.  In another study, Minio-Paluello, Baron-Cohen, Avenanti, Walsh, and Aglioti (2009) found that individuals with Asperger's syndrome demonstrated a paucity in empathic responses to the observation of painful stimuli in other people as measured through single-pulse transcranial magnetic stimulation.  His work is thus providing a strong biological foundation for our understanding of the autism spectrum.

All this being said, in his NYT editorial this morning, Dr. Baron-Cohen opined that the proposed changes related to the Asperger's diagnosis are premature for a number of reasons.  First, because the DSM system is not based upon taxometric analyses, it is unclear whether our diagnostic entities represent naturally occurring, distinct groups and, as such, reshuffling the deck in a substantial way might not represent valid scientific progress.  Secondly, he wonders whether this shift would cause distress and confusion for individuals who have received the Asperger's diagnosis and potentially negatively impact their ability to obtain services.  Third, he claims that the scientific world has not had enough time to test for biological differences between Asperger's and other ASC's - Asperger's syndrome was not added until DSM-IV, after all - and, as such, removal would prevent a clear understanding of the phenomenon.

Point 1: Taxometrics

Put briefly, taxometrics refers to the process of analyzing whether an entity represents a naturally occurring group (a taxon) or a dimensional construct.  A couple significant issues in mental health research are the degree to which we can provide a single comprehensive definition of mental illness and the degree to which the diagnoses listed within the DSM (or ICD) represent naturally occurring phenomena as opposed to man-made collections of symptoms of questionable validity.  Taxometric analyses can, at least to an extent, provide answers to those questions (for a reader friendly review of this topic, I recommend Joiner & Schmidt, 2002 and Schmidt, Joiner, & Kotov, 2004.  See our References page for the full citations).

In an early lecture during my first year in graduate school, Brad Schmidt explained the concept of taxometrics to me and my classmates in a distinctive manner that has stayed with me ever since:  "There are gophers and there are chipmunks but there are no gophmunks."  In other words, gophers and chipmunks both represent taxa - naturally occurring qualitatively distinct groups and do not lie upon a single gopher-chipmunk continuum. 

Dr.Baron-Cohen is absolutely correct in arguing that the DSM is not based upon taxometrics.  I wanted to respond to the comment not to argue, but rather to call attention to some of the work that is going on out there on this topic because, in reality, a number of researchers are, in fact, making serious attempts to examine the degree to which diagnostic categories (or features within diagnoses) represent a taxon versus a continuum.  For instance, research supports the idea that schizotypy is taxonic, (e.g., Lenzenwager & Korfine, 1992).  Additionally, whereas research indicates that antisocial behavior and personality appear to be taxonic (e.g., Skilling, Quinsey, & Craig, 2001), psychopathy falls along a continuum (e.g., Marcus, John, & Edens, 2004).  Some researchers have demonstrated that depression is a dimensional construct (e.g., Ruscio & Ruscio, 2000); however, others have found support for the notion that depressive subtypes (e.g., melancholic depression) are taxonic (e.g., Haslan & Beck, 1994).  Some research supports the possibility of eating disorder taxa (Gleaves, Lowe, Snow, Green, & Murphy-Ebernez, 2002; Williamson, et al., 2000).  Within anxiety, worry and PTSD have been shown to be non-taxonic (Ruscio, Borkovec, & Ruscio, 2001; Ruscio, Ruscio, & Keane, 2002), whereas general anxiety and anxiety sensitivity have demonstrated evidence of being taxonic (Kotov, Schmidt, Lerew, Joiner, & Ialongo, 2005; Schmidt, Kotov, Lerew, Joiner, & Ialongo, 2005 - and thanks to Jill Holm-Denoma and Tony Richey, whose earlier work guided me to these articles).  The point in all of this is that we are making progress on this issue and that changes made in the DSM-V with respect to dimensional diagnoses will not be based purely upon committee opinions, but also a growing mountain of empirical research on the validity of such distinctions.

Point 2: The impact of the change on people with the diagnosis

Obviously, I can not speak for individuals with ASCs regarding how this change would impact them.  A fascinating comment in the comment section of the prevous PBB article on this topic, however, provides an interesting perspective from an individual who reports having Asperger's syndrome and I highly recommend that you read the comment.  No doubt, changing the Asperger's diagnosis such that it falls into an autism spectrum disorder continuum will confuse and frustrate some.  Based upon the comment I just referenced, it also will provide relief to others.  The question of the impact of this move, however, does not speak to the validity of the move.  In other words, if changing the Asperger's diagnosis in this manner represents a more accurate description of the nature of ASC's but it causes distress, the problem is in the way we are educating individuals on the topic, not with the diagnostic shift.  In this sense, it seems that providing awareness on these issues, which is always paramount, would simply become even more important should the DSM choose to make such a drastic change.

One point that Dr.Baron-Cohen made a few times in discussing this and with which I do agree is the idea that the Asperger's diagnosis is being "removed."  Removal indicates that individuals who meet criteria for Asperger's would no longer meet criteria for a diagnosis and, as such, their symptoms would either not be assessed in the first place or not result in services being provided.  This, however, is not the case.  Individuals who met criteria for Asperger's using DSM-IV-TR criteria would simply meet criteria for autism spectrum disorder instead.  Plus, as was mentioned in the previous NYT article, receiving services for an autism diagnosis is easier in most states than is receiving services for Asperger's and, as such, this shift does not seem like to result in a loss of services.  Confusion is a legitimate consideration, but the disorder is not being removed and clarification of that point is not beyond the realm of possibility.  Nonetheless, Dr.Baron-Cohen's point highlights an important underlying message - that changes to the diagnosis will impact a substantial number of people in a variety of ways, so clarity of message and purpose will be pivotal.

Point 3: Giving the scientific community time

I'm on the fence on this issue.  I do agree with Dr.Baron-Cohen that we should be deliberate in our shifts and base them on evidence accumulated through systematic investigations of the issues.  Doing so is a fundamental premise of scientific pursuit.  That being said, how much time is enough time for scientists to uncover biological differences between ASC's that would justify keeping the subtypes separate in the face of mounting evidence that they are part of a single continuum?  Additionally, to what degree are we making an unsubstantiated assumption that mental disorders all have a readily identifiable biological underpinning rather than an environmental or bi-directional cause?  The concept of multi-finality - that several things can lead to the same outcome - speaks to the danger of waiting for the discovery of a single cause (this was, in fact, a major weakness of original versions of the DSM, which relied heavily upon psychodynamic theories of etiology in the absence of supportive evidence).

In a prior study, Dr.Baron-Cohen himself has indicated that ASC's exist along a continuous gradient of severity (Ring, Woodbudy-Smith, Watson, Wheelwright, & Baron-Cohen, 2008) and, in the NYT article this morning, he readily stated that he is one of the biggest believers in an autism spectrum.  At the same time, he mentioned that he has recently published a study the reports on 14 genes associated with Asperger's.  I was unable to find a copy of this study (if anyone has a copy and can direct me to a resource to find it, I would greatly appreciate it!), so it is unclear if these genes distinguished those with Asperger's from those with other ASC's (evidence that the spectrum diagnosis is unwarranted) or simply from individuals without an ASC (evidence that does not address the question at hand).  It will be very interesting to learn more about that topic.  Regardless, his position seems to be that there is reason to believe that more answers will emerge soon that would clarify this matter and that, as such, DSM-V is not the appropriate time for such a shift.  Importantly, he is not saying that the shift should never be made, but rather that more evidence on the matter must be produced.

Summary

My goal today was to provide you with a perspective from an expert that goes somewhat against some of what we on PBB and others have said about potential shifts in autism spectrum diagnoses in DSM-V.  As you can probably see, there are compelling arguments on both sides and many people who will be impacted regardless of the final decisions.  My personal opinion is that we should go where the evidence leads us and that, as of now, the evidence is more consistent with a single continuum model.  That being said, clearly there are highly informed, highly experienced individuals who think otherwise.  Given the information presented on both sides, I am curious where you stand.  Does the evidence support keeping these diagnoses separate from one another or is a continuous model more accurate?  Regardless of accuracy, would the impact of the shift be harmful or are such fears based more on guesswork than evidence?  Any thoughts that add to this conversation will be a welcome addition to the site.

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If you would like to learn more about the topics covered on PBB, we encourage you to consult our online store of scientifically-based psychological resources.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Reshaping autism spectrum diagnoses in DSM-V

by Michael D. Anestis, M.S.

Few issues in clinical psychology prompt as many varied and strong responses as discussions of autism and autism spectrum disorders (e.g., Asperger's disorder).  Individuals argue about potential origins, treatments, assets, and liabilities associated with these symptom patterns and, quite understandably, emotions often drive the course of the discussion.  As always, we at PBB are primarily concerned with scientific evidence and how it can help shape our view of mental health topics and better enable us to validly and reliably diagnose and subsequently treat patients in such a manner as to maximize the number of individuals in need receiving the optimal form of treatment.  That being said, today I would like to discuss an article written by Claudia Wallis and published in the Health section of the New York Times on potential shifts in the autism diagnostic spectrum in the upcoming DSM-V.  In prior DSM-V articles, our focus has been on peer-reviewed journal articles and, as we continue to touch on this topic, that will remain our general focus, but this New York Times article was exceptionally well-written and I find myself compelled to make it the center of today's post.

One of the primary reasons I feel compelled to write about this topic - aside from the fact that I feel these disorders should receive more attention on PBB than they have thus far - is that I so often encounter or read about people whose lives are shaped by autism spectrum disorders and who are wading through a sea of information, much of which is not based upon any scientific evidence.  One of the primary sources of concern - increased prevalence - has led many people to fear that there is an autism "epidemic," as though the disorder is occurring in more people now than it was before.  The key, however, is that people must differentiate between prevalence and incidence.  The former term refers to how often a disorder is diagnosed.  The latter term refers to how often it actually occurs.  When a diagnosis becomes more widely known, more people seek treatment due to its symptoms and more clinicians assess for its presence (and insurance companies become more likely to pay for its treatment).  As such, prevalence is sure to increase, but not because more people actually have the disorder (incidence).  Additionally, as was the case with autism spectrum disorders, when milder variants become publicized and added to the diagnostic manual, a greater number of individuals who previously would have fallen beneath the diagnostic threshold are likely to receive diagnoses.  Here again, prevalence increases not because more people have symptoms, but because we discover and acknowledge the symptoms in a greater number of people who have them.  As such, much of the concern regarding a potential autism epidemic actually reflects an increased number of individuals receiving diagnoses due to a greater amount of publicity and more sensitive diagnostic criteria.

At the core of the New York Times article is one substantial decision that appears to be increasingly likely and which directly impacts the increased prevalence of autism spectrum disorders: the merger of Asperger's disorder and pervasive developmental disorder not otherwise specified (PDD-NOS) into a single diagnosis (click here to read the DSM-IV-TR diagnostic criteria for each of these conditions).  As Catherine Lord, director of the Autism and Communication Disorders Centers at the University of Michigan said in the article, "Nobody has been able to show consistent differences between what clinicians diagnose as Asperger's syndrome and what they diagnose as mild autistic disorder."  In other words, it appears that Asperger's disorder might not actually be qualitatively different from mild autism and that, by collapsing the diagnoses into a single continuum, we might develop a more accurate conceptualization of the autism spectrum and reduce the confusion caused by situations in which individuals appear to transition from one spectrum diagnosis to another and then back again.

Scientifically speaking, this decision makes a lot of sense, but that does not mean that it is without its potential problems.  First of all, people are used to the terminology.  Much as people continue to use terms like "ADD" and "sociopath" rather than "ADHD, primarily inattentive type" and "psychopath," the shifting away from the well-known term "Asperger's" is likely to result in confusion regarding terminology, particular amongst clinicians who do not remain up to date on current research and individuals in need of help who are not plugged in to the inner workings of the scientific psychological community. 

Another concern, as we mentioned above, is that the inclusion of specific diagnoses at the milder end of the autism spectrum resulted in an increase in individuals being assessed for symptoms and subsequently receiving help.  Some individuals are concerned that, by merging the diagnosis with a broader autism spectrum, the result might be that a smaller number of individuals with mild symptoms will be assessed.  Personally, I do not buy into this argument, although I understand where it is coming from.  The way I see it, the broader spectrum includes Asperger's as well as people with milder and more severe symptoms.  If clinicians do not assess for symptoms or individuals in need of help do not seek services, this is not necessarily representative of a problem with the diagnostic framework, but rather a systemic failure indicating that proper procedures are not being followed by practitioners and adequate information is not being provided to those in need.  The fear of mistakes should not prevent us from making progress and increasing accuracy.  Instead, it should motivate us to address the issues likely to result in those mistakes.

A third concern expressed in the New York Times article is the idea that, whereas most people have a positive or neutral view of Asperger's disorder, the same is not true of autism and, as such, the connotation of the diagnostic terms might inhibit some people from seeking services.  Here again, I can see where people are coming from with the argument, but that line of thinking makes me a bit uneasy.  It seems that, in maintaining that perspective, we are perpetuating unnecessary and hurtful views of the more severe side of the autism spectrum and, in a sense, making an already difficult situation even harder to manage.  The answer is not to deepen the public's divided perception of variants within the autism spectrum, but rather to enlighten them and reduce stigma.  In this sense, collapsing the diagnoses into a single spectrum is not only scientifically valid, but also potentially a useful social maneuver that can help alleviate false beliefs about the differences between these conditions.

So far, we have talked entirely about potential problems of the proposed DSM-V shift, but there are many compelling positives likely to stem from this move as well.  First of all, as the New York Times article notes, the changes would allow for a shift away from an all-or-nothing, "you have it or you don't" view of autism spectrum disorders and towards a continuous view that recognizes differences in symptom patterns and severity.  Secondly, the DSM-V task force is seeking to also include measures of a number of additional health problems frequently associated with autism spectrum disorders but not currently included as DSM symptoms.  Along these lines, DSM-V will hopefully include measures of anxiety, attention difficulties, gastrointestinal problems, seizures, and sensory sensitivities (e.g., aversion to loud noises) along with measures of the core autism symptoms.  In this sense, the entirety of the disorder will be recognized and, in all likelihood, a substantial increase in research addressing this broader picture will commence. 

The New York Times article also notes that, in some states (e.g., Texas and California), only a diagnosis of autism proper results in receiving state services.  Individuals diagnosed with Asperger's disorder or PDD-NOS are not eligible there.  By recognizing that these disorders lie upon a single continuum rather than representing qualitatively distinct phenomena, the DSM-V would likely enable a larger proportion of those with such symptoms to become eligible for services.

One final point mentioned in the article is worth noting.  Autism spectrum disorders look different in different people.  In fact, two people who meet criteria for one of these conditions might not appear similar at all.  In this sense, as Susan Swedo of NIMH said, "in autism, everybody is a snowflake."  Given this variability, the elimination of subtypes might seem counter-intuitive.  After all, if people can look so different from one another, shouldn't we be making an effort to systematically understand those differences?  The answer, quite clearly, is yes, but the decision to eliminate subtypes at this point is nonetheless a reasonable thought.  As of now, none of the genetic variants identified by researchers maps onto the subtypes we have defined and very little statistical evidence supports the discriminant validity of the subtypes whereas substantial evidence contradicts it.  Along these lines, until we can develop more valid and reliable subtypes, it makes more sense to eliminate the ones we have rather than perpetuate our beliefs in the wrong subtypes.

None of these decisions are final.  I have heard rumors about many of these thoughts for years and, certainly, there is reason to believe that they will come to pass, but nothing has been finalized.  Additionally, in January, the work group's final proposal for DSM-V will be posted on the DSM-V website and the public will be invited to submit comments.  Obviously, not everybody's voice will be heard, but this will provide people with an opportunity to express their thoughts and to read and contemplate the perspectives of others.  Without question, the comment section will be full of emotions and the results should be interesting to see.

All this being said, I would love to hear your thoughts on these proposals.  Do you think that merging the Asperger's diagnosis with PDD-NOS will have harmful effects, beneficial effects, or a combination of the two?  Do you see a better solution?  Is a solution even necessary?  I know there are numerous PBB readers with strong backgrounds in this area and I am certain that all readers would benefit from reading your thoughts on this matter, regardless of where you stand on the issues.

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If you would like to learn more about any of the topics discussed on PBB, we hope you will consult our online store of scientifically-based psychological resources

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Revising PTSD for DSM-V: An update on diagnostic controversies

by Michael D. Anestis, M.S.

Post-traumatic stress disorder (PTSD) is a debilitating condition worthy of the vast amount of research attention it receives.  Few, if any, disagree with this point.  That being said, substantial disagreement exists regarding the ideal set of criteria to be used in determining whether or not an individual is, in fact, suffering from this disorder.  As committees meet to discuss the upcoming DSM-V, this issue is picking up steam and, in the current issue of the Journal of Traumatic Stress, a number of psychologists put forth arguments for how they believe the DSM-V criteria for PTSD should look.  Before discussing their points, let's first take a look at the PTSD criteria as they are in the current diagnostic guide, the DSM-IV (p.467):

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Criterion A: The person has been exposed to a to a traumatic event in which both of the following were present -

1. the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
2. the person's response involved intense fear, helplessness, or horror (in children, can be expressed through disorganized or agitated behavior)

Criterion B: The traumatic event is persistently reexperienced in one (or more) of the following ways:

1. recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions (in children, repetitive play may occur in which themes or aspects of the trauma are exposed)
2. recurrent distressing dreams of the event (in children, there may be frightening dreams without recognizable content)
3. acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated)
4. intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
5. physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Criterion C: Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. efforts to avoid activities, places, or people that arouse recollections of the trauma
3. inability to recall an important aspect of the trauma
4. markedly diminished interest or participation in significant activities
5. feeling of detachment or estrangement from others
6. restricted range of affect (e.g., unable to have loving feelings)
7. sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Criterion D: Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

1. difficulty falling or staying asleep
2. irritability or outbursts of anger
3. difficulty concentrating
4. hypervigilance
5. exaggerated startle response

Criterion E: Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month

Criterion F: The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

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Of all the DSM diagnoses, this one might be the most wordy, but that is besides the point.  The criticisms of PTSD stem not from its diagnostic wordiness, but rather contentions that several people have about particular criteria, as well as the underlying nature of the disorder itself.  With respect to that latter point, some individuals claim that the PTSD diagnosis pathologizes normal distress.  In other words, it is perfectly natural for people to become upset after something traumatic happens, but such distress will run its course naturally.  Research has shown, however, that individuals diagnosed with PTSD often still meet criteria many years later (e.g., Morgan, Scourfield, Williams, Jasper, & Lewis, 2003).  Such findings indicate that, while being upset by trauma is normal, extreme responses exist that require clinical attention. 

Other critiques of PTSD center on the symptom overlap it shares with other diagnoses.  This, of course is not a problem unique to PTSD.  Many anxiety disorders share criteria with one another (e.g., avoidance behavior) and generalized anxiety disorder and depression exhibit a substantial amount of symptom overlap.  Nonetheless, the point remains that, to some degree, the PTSD diagnosis might include symptoms that are reflective of overall distress or another diagnosis rather than simply applying to this one specific disorder.

A third critique - the one that has been subject to the most attention - is the inadequacy and utility of Criterion A.  In other words, a substantial number of people question whether the diagnosis of PTSD should actually require exposure to a specific traumatic event and a response to that event that was characterized by extreme fear, horror, or hopelessness.  Some people argue that this criterion prevents people who meet all other criteria from receiving a legitimate diagnosis and subsequent treatment.  Others argue that the broadening of the definition that occurred with the publication of DSM-IV has led to a "criterion creep," allowing for diagnoses of individuals who were exposed to traumatic events that are not viewed as legitimate causes of PTSD (e.g., watching frightening Halloween television programs, losing cattle to foot and mouth disease; Rosen & Lilienfeld, 2008).  Research conducted by Breslau and Kessler (2001) revealed that the broadening of Criterion A did, in fact, result in an increased number of PTSD cases, but that the vast majority of those new cases involved individuals learning about the sudden unexpected death of a loved one.

All this being said, there is a fairly strong movement afoot to remove Criterion A in DSM-V.  When I first heard this, I was highly skeptical and, in fact, in discussions I have had on this topic with my students in Abnormal Psychology, we have often come to a consensus opinion that this move would not make sense.  After reading two articles (one on each side of the argument) in this special issue of the Journal of Traumatic Stress, however, I actually have now changed my opinion.  My goal with the rest of this article is to explain the proposed models of these two articles and their justification so that you can make an informed decision as well and lend your voice to the discussion.

Brewin, Lanius, Novac, Schnyder, & Galea (2009)

Brewin and colleagues (2009) propose that the DSM-V should eliminate Criterion A and, in doing so, refocus the diagnosis of PTSD around a specific set of core symptoms unique to this particular disorder.  They argue that no other mental illness requires a specific etiology and that, in fact, demanding that a disorder be prompted by a single environmental event while excluding the roles of characteristics of the individual and the interaction of personal characteristics with environment is an overly simplistic way of thinking about mental illness.  Indeed, this does seem to discount the idea of the diathesis-stress model.  Not everybody responds to the same event in the same way or views particular events as equally traumatic, so requiring a specific triggering traumatic event introduces substantial bias to the diagnostic criteria and shifts focus away from the degree of suffering being experienced by the client.  They also argue that, after three revisions of this criteria, we still find ourselves unable to articulate a description that ensures that all appropriate cases are included and all inappropriate cases are excluded.  There is little reason to believe this would change in DSM-V.

In the field trials for DSM-IV (Kilpatrick et al., 1998), adjusting the definition of Criterion A to include low magnitude events had almost no impact of prevalence rates.  In other words, by creating a situation in which a specific trigger does not have to be identified and events not typically considered traumatic were included, the researchers running the field trial actually did not cause a steep increase in PTSD diagnoses.  

Brewin and colleagues (2009) thus believe that, in the DSM-V, PTSD should be based around the core phenomenon of "re-experiencing in the present, in the form of intrusive multi-sensory images accompanied by marked fear or horror, an event now perceived as having severely threatened a person's physical or psychological well-being."  In other words, if the individual is having flashbacks of past events, the core of the disorder is present whether or not the individual can identify a specific event that prompted all of his or her symptoms and a response to that event that involved specific emotions.  Doing this places an emphasis on the symptoms that are present and are unique to PTSD rather than the individual's recollection of past events and feelings.  In this sense, we would become more concerned with treating what is present than in discussing what occurred in the past.  To me, this sounds eerily familiar to one of the main arguments for why empirically supported treatments such as cognitive behavioral therapy outperform old fashioned therapeutic approaches like psychoanalysis for so many diagnoses.  If people are suffering, it does not matter why as much as it matters how they are suffering and what can be done to improve that individual's quality of life.  If PTSD symptoms are induced by something that most people would not view as traumatic...who cares?  Perhaps individual differences in variables such as distress tolerance cause particular individuals to experience particular events as more problematic than others.  If such individuals exhibit the same core symptoms and will respond to treatment just as well, why not include them in the diagnosis?

Kilpatrick, Resnick, & Acierno (2009)

A second article in the same issue of the Journal of Traumatic Stress arrived at an entirely different conclusion. Like Brewin and colleagues (2009), Kilpatrick and colleagues (2009) acknowledged the imperfections of the PTSD diagnosis and contested the notion of "criterion creep;" however, they believe that the core nature of PTSD requires Criterion A and that revisions are a better answer than elimination.

Their rationale for this suggestion centered on a number of specific points.  First, because they believe that PTSD is a disorder that does not occur spontaneously and always follows exposure to some stressful event, removing Criterion A would be inconsistent with the nature of the disorder.  Second, they believe that, because the DSM-IV field trails revealed that few people meet the other criteria for PTSD without meeting Criterion A, it makes more sense to simply increase flexibility to include the few cases that might otherwise get lost rather than eliminating the criterion altogether.  Third, the authors argued that the better focus is on which events are most likely to induce PTSD, rather than which events should qualify.  Ultimately, the authors also argued that revision would allow for a DSM-V criteria set more consistent with prior research on the topic.

Ultimately, these authors acknowledged the imperfections, but believe that revising the criteria while remaining consistent with the research already conducted on this issue makes more sense than a massive reboot of the construct involving elimination of Criterion A.

My thoughts

Reading through these discussions, I was surprised to find myself suddenly agreeing with the idea of eliminating Criterion A.  My basis for this opinion change is a shifting understanding of the real question here.  The bottom line is, diagnoses serve to recognize suffering and to determine which individuals are ideal candidates for particular treatments.  As such, the priority should be on maximizing our ability to reliably and validly identify suffering, not on determining a particular event that prompted the symptoms in the first place.  Unless research indicates that particular prompting events result in differential responses to particular treatments, what is the point in being hung up on the prompting event?  If it is there, and it likely is in the vast majority of cases, it will be clear in the client's flashbacks and nightmares and can thus be adequately addressed in treatment.

My shifting opinion was not only influenced by the compelling arguments of Brewin and colleagues (2009), but also by some weaknesses I saw in the Kilpatrick et al (2009) argument.  In their first rationale for revision instead of elimination, they said that PTSD is a disorder that does not occur spontaneously.  First of all, this is an assumption.  Secondly, it is circular reasoning.  Essentially, this argument says "because the criteria currently say that PTSD is caused by a specific event, we can not change the criteria such that they do not require a specific event, otherwise that would be inconsistent with criteria that require a specific event."  Regardless of the strength of the argument, however, if it is impossible to experience the symptoms of PTSD without Criterion A, than what is the point of including it in the diagnostic criteria?  Doesn't this logic imply that, if Criteria B-D are met, Criterion A is all set?  Additionally, although I value incremental steps in research that build off of one another and help to develop a nomological net, the desire to remain consistent with prior literature is not a rationale for ignoring changes based upon evidence.  Consistency only has value when we are being consistently accurate.

I also found myself a bit taken aback that the results of the DSM-IV field trials were used to support the conclusions of both studies.  In other words, authors on two completely opposite sides of an argument both cited the same piece of evidence as supporting their case.  This either speaks to a lack of quality in the evidence, or a misunderstanding of the data by some or all of the authors.

Given that my opinion on this matter has shifted drastically, I am not at all convinced that it will not shift back as I read more on the topic.  In the meantime, I am curious what you think about this situation.  Should Criterion A be a part of the PTSD diagnosis in DSM-V?

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If you would like to learn more about PTSD and its treatment, we recommend the following items, all of which are available through our online store of scientifically-based psychological resources:

• Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide by Edna Foa, Elizabeth Hembree, and Barbara Rothbaum

• Cognitive Processing Therapy for Rape Victims: A Treatment Manual by Patricia Resick and Monica Schnicke

• Prolonged Exposure Therapy for Adolescents with PTSD Emotional Processing of Traumatic Experiences, Therapist Guide by Edna Foa, Kelly Chrestman, and Eva Gilboa-Schnechtman
  

• Reclaiming Your Life from a Traumatic Experience: A Prolonged Exposure Treatment Program Workbook by Barbara Rothbaum, Edna Foa, and Elizabeth Hembree

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University