I have written before about the DSM-5 process, including criticisms that the process is not transparent and that it is dominated by psychiatrists with histories of consulting to pharmaceutical companies, and that the process of revising DSM is driven by the royalties that the American Psychiatric Association depends on selling new copies to pay for its expenses.

Now the proposed criteria are out, but the link did not work for gender identity disorders or dissociative disorders, although this is the last day for comments. The PTSD criteria were present and I had the following critiques which I posted there.

There are no plans to do a field trial to compare prevalence of PTSD under the new criteria compared to DSM-IV-TR. We will unleash a diagnostic classification system with no idea about the impact it will make on diagnosis. This will increase overnight the number of people who meet criteria for the disorder, with the associated stigma and risk of adverse effects of treatment. The new “Criteria A” expands the number exposed from half the population to probably all of the population (although we don’t know for sure, as there are no studies). Anyone who has witnessed death or threatened death, or threatened sexual violation, or heard about it from a close friend or relative, or heard about aversive details. It doesn’t matter how they reacted, as the stipulation “associated with intense fear, horror or helplessness” has been removed. Some symptoms like “I’ve lost my soul forever” are grounded in JudeoChristian beliefs (this last one makes me wonder if the lights are on in there).
Did you know that you don’t have to use the DSM or buy it? Yep. All you need is the ICD-9 codes for insurance or billing purposes.That’s the APA’s dirty little secret.

Here are the proposed criteria for PTSD

Posttraumatic Stress Disorder*

A. The person was exposed to the following event(s): death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways:**

1.Experiencing the event(s) him/herself2.Witnessing the event(s) as they occurred to others
3.Learning that the event(s) occurred to a close relative or close friend
4.Experiencing repeated or extreme exposure to aversive details of the event(s) (e.g., first responders collecting body parts; police officers repeatedly exposed to details of child abuse)NOTE: Witnessing or exposure to aversive details does not include events that are witnessed only in electronic media, television, movies or pictures, unless this is part of a person’s vocational role. Exposure to aversive details of death applies only to unnatural death.

B. Intrusion symptoms that are associated with the traumatic event(s) (that began after the traumatic event(s)), as evidenced by 1 or more of the following:

1.Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
2.Recurrent distressing dreams in which the content and/or affect of the dream is related to the event(s). Note: In children, there may be frightening dreams without recognizable content. ***
3.Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.
4.Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
5.Marked physiological reactions to reminders of the traumatic event(s)
C. Persistent avoidance of stimuli associated with the traumatic event(s) (that began after the traumatic event(s)), as evidenced by efforts to avoid 1 or more of the following:

1.Thoughts, feelings, or physical sensations that arouse recollections of the traumatic event(s)
2.Activities, places, physical reminders, or times (e.g., anniversary reactions) that arouse recollections of the traumatic event(s)
3.People, conversations, or interpersonal situations that arouse recollections of the traumatic event(s)
D. Negative alterations in cognitions and mood that are associated with the traumatic event(s) (that began or worsened after the traumatic event(s)), as evidenced by 3 or more of the following: Note: In children, as evidenced by 2 or more of the following:****

1.Inability to remember an important aspect of the traumatic event(s) (typically dissociative amnesia; not due to head injury, alcohol, or drugs).
2.Persistent and exaggerated negative expectations about one’s self, others, or the world (e.g., “I am bad,” “no one can be trusted,” “I’ve lost my soul forever,” “my whole nervous system is permanently ruined,” “the world is completely dangerous”).
3.Persistent distorted blame of self or others about the cause or consequences of the traumatic event(s)
4.Pervasive negative emotional state — for example: fear, horror, anger, guilt, or shame
5.Markedly diminished interest or participation in significant activities.
6.Feeling of detachment or estrangement from others.
7.Persistent inability to experience positive emotions (e.g., unable to have loving feelings, psychic numbing)
E. Alterations in arousal and reactivity that are associated with the traumatic event(s) (that began or worsened after the traumatic event(s)), as evidenced by 3 or more of the following: Note: In children, as evidenced by 2 or more of the following:****

1.Irritable, angry, or aggressive behavior2.Reckless or self-destructive behavior
3.Hypervigilance
4.Exaggerated startle response
5.Problems with concentration
6.Sleep disturbance — for example, difficulty falling or staying asleep, or restless sleep.
F. Duration of the disturbance (symptoms in Criteria B, C, D and E) is more than one month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

With Delayed Onset: if diagnostic threshold is not exceeded until 6 months or more after the event(s) (although onset of some symptoms may occur sooner than this).
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165

In this recent piece from Howard Brody MD of the Hooked blog about how the American Psychiatric Association (APA) recently voted to eliminate pharmaceutical industry funding of educational symposia as well as free meals etc. from their annual meeting, he asks what they will do to pay for their education. I am not involved in the politics of the APA (or any other organization, for that matter, not that I shouldn’t be based on my research accomplishments, but maby they just think I am a curmudgeon or something. And neither me nor Mrs. Bremner have ever gotten one of those lifetime achievement awards).

The last time I went to an APA meeting it was in New York several years ago and I took my daughter so we could have a bonding experience and see the sights. I typically have gone to the American College of Neuropsychopharmacology (ACNPee pee) which doesn’t have overt drug sales displays but which is perhaps a more covert form of drug company coercion after all, so I am going to have to look into doing something at APA given these new rules (and forgoing ACNP). Good job guys. And hat tip to Danny Carlat who has gotten involved in the internal politics of education within the APA and surely must have played a role in this decision.

The fact is that the APA is the first medical organization to make such a move and hats off to them. Let’s celebrate.

Yeah! The wicked drug company is dead!

Howard quoted someone from the APA saying that without drug companies they would have to hold their lectures at the YMCA. Well I think I have a pretty good analogy for you. For one of our NIH funded grants we added as a consultant Lori Davis MD of the Tuscaloosa VA and the University of Alabama Birmingham Department of Psychiatry. Lori came over to Atlanta and gave a lecture on “Diagnosis and Treatment of PTSD” and then met with our staff and fellows to review diagnostic assessments of PTSD. She will return in May. The lecture was delivered in the auditorium of the old Georgia Mental Hospital which is now owned by Emory and called Emory Briarcliff. Not the Ritz, but no overhead, free, easy, and free of commercial influence. Isn’t that the way it should be?