Early Thoughts Toward a Relational Diagnostic Manual of Emotional Dysfunction

The DSM-5 has been the target of criticism since nearly the first days of the implementation of the revision process. Allen Francis, MD, who was the chair of the DSM-IV task-force, has been monitoring the issues from the beginning and has been one of the most critical voices - much of it on his Psychology Today blog, DSM5 in Distress.

I think it's long-overdue that we create a diagnostic model based on what we see in the room with clients, not on relatively disconnected biological models of mental illness. This post lays out why this is needed and then offers a few basic ideas toward what that manual might look like. 

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Recently, it became public knowledge that two members of the personality disorders working team, Roel Verheul, Ph.D. and W. John Livesley, M.D., Ph.D. resigned as members of the DSM-5 Personality and Personality Disorders Work Group in April. In their email to Dr. Allen Francis, they said the following as to their reasons:

"We resigned from the DSM-5 Personality and Personality Disorder Work Group in April 2012 with a mixture of sadness and regret. We believed that the construction of DSM-5 afforded an important opportunity to advance the study of personality disorder by developing an evidence-based classification with greater clinical utility than DSM-IV. The data and conceptual tools for such an undertaking have been available for some time and the field seemed to recognize the need for change. Regrettably, the Work Group has been unable to capitalize on the opportunity and has advanced a proposal that is seriously flawed. It has also demonstrated an inability to respond to constructive feedback both from within the Work Group and from the many experts in the field who have communicated their concerns directly and indirectly. We also regret the need to resign because we were the only International members of the Work Group which is now without representation from outside the US.

Early on in the DSM-5 process, we developed major concerns about the Work Group's mode of working and its emerging recommendations that we communicated to the Work Group and Task Force. We did not resign earlier because we continued to cherish the hope that eventually science and common sense would prevail and that there would be an opportunity to construct a coherent, evidence-based classification that would help to advance the field and facilitate patient care. In the spring of this year, it became apparent that is was not going to happen. We considered the current proposal to be fundamentally flawed and decided that it would be wrong of us to appear to collude with it any longer.

 As we see it, there are two major problems with the proposal. First, the proposed classification is unnecessarily complex, incoherent, and inconsistent. The obvious complexity and incoherence seriously interfere with clinical utility. Although the proposal is touted as an innovative and integrative hybrid system, this claim is spurious. In fact, it consists of the juxtaposition of two distinct classifications (typal and dimensional) based on incompatible models without any attempt to reconcile or integrate them into a coherent structure. This structure also creates confusion since it is not clear whether the clinician should use one or both systems in routine clinical practice.

Second, the proposal displays a truly stunning disregard for evidence. Important aspects of the proposal lack any reasonable evidential support of reliability and validity. For example, there is little evidence to justify which disorders to retain and which to eliminate. Even more concerning is the fact that a major component of proposal is inconsistent with extensive evidence. The latter point is especially troublesome because it was noted in publication from the Work Group that the evidence did not support the use of typal constructs of the kind recommended by the current proposal. This creates the untenable situation of the Work Group advancing a taxonomic model that it has acknowledged in a published article to be inconsistent with the evidence.

For these and other reasons, we felt that the only honest course of action was to resign from the Work Group. The current proposal represents the worst possible outcome: it displays almost total discontinuity with DSM-IV while failing to improve the validity and clinical utility of the classification. Not surprisingly, the proposal has received widespread criticism to which the Work Group seems impervious."

These criticisms are specific to just the Axis II section of the DSM, which deals with personality disorders. An earlier announcement, from back in July, 2011, offered the following statement on its new section for personality disorders:

As recommended by the DSM-5 Personality and Personality Disorders Work Group, 10 categories will be reduced to six specific personality disorder types (antisocial, avoidant, borderline, narcissistic, obsessive/compulsive and schizotypal).

The four that have been dropped are dependent, paranoid, schizoid, and histrionic. The inclusion of the borderline diagnosis, despite widespread belief among therapists and counselors that a borderline diagnosis is both too stigmatizing and inaccurate, is disturbing. Because of the stigma associated with a borderline diagnosis, many therapists will not treat them.

Bessel van der Kolk has long advocated for a Developmental Trauma Disorder to replace borderline as a diagnosis and to differentiate early childhood trauma (complex PTSD) from adult trauma (PTSD). He acknowledges Marylene Cloitre, Julian Ford, Alicia Lieberman, Frank Putnam, Robert Pynoos, Glenn Saxe, Michael Scheeringa, Joseph Spinazzola, Allan Steinberg, and Martin Teicher in  the creation of a proposed diagnosis of Developmental Trauma Disorder.

Back in May, 2012, Dr. Francis wrote about the rather disturbing failure of the field trials for the new DSM-5 diagnostic criteria.

This failure was clearly predictable from the start: 1) The writing of the DSM 5 criteria sets was far too raw and imprecise to be ready for the rigors of field testing. The ambiguity cried out for expert editing; without which reasonable reliability is impossible; 2) The design of the field trial was byzantine in complexity and could never be done on schedule: 3) Constant delays in starting and completing Stage 1 of the study forced DSM 5 to cancel the planned Stage 2 that was meant to clean up the poorly performing criteria sets identified in the first stage. 4) With stage 2 cancelled without explanation, it looks like even the worst diagnoses are being given a social pass; and, most absurd, 5) The design was totally off point, failing to ask the only question that really counted ( the impact of DSM 5 on rates).

Dr. Francis describes the results as a disgrace to the field. It's hard to not agree.

The DSM Is Written by Psychiatrists

One of the most serious flaws with the DSM, in my opinion, is that it is written by psychiatrists, medical doctors with some training in psychoanalysis. When the first versions of the DSM came out, psychiatrists were the only people practicing therapy. But in the 1960s and 1970s we experienced the medicalization of psychiatry as the first antidepressants and antipsychotics were developed.

A lot of psychiatrists don't even do talk therapy anymore. According to the New York Times:

A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.

For those who take insurances, psychiatrists can earn as much as $150 for three 15-minute "med checks" compared to only $90 for a 50-minute psychotherapy session. Another more recent study (discussed in Internal Medicine News) suggests that there has been a serious decline in the use of talk therapy over the last 20+ years.

When asked how they treated patients during their most recent typical week, 48% said that they used psychotherapy and 89% said that they used pharmacotherapy – either in combination or as monotherapy – in an analysis that weighted responses based on the number of patients each psychiatrist treated. For psychotherapy, the 48% prevalence of use compared with 68% in a 2002 survey and 72% in a 1988 survey. The drug therapy rate of 89% in 2010 compared with 81% in 2002 and 54% in 1988.

As the New York Times article made clear, a large part of the decline can be attributed to changes in insurance reimbursement policies. If a psychiatrist can make $50 for a 15-minute med check or $90 for a 50-minute therapy session, the choice is clear for many. If a doc doesn't take insurances, s/he can make $120 for a 15-minute med check (x3 for $360/hr) or $150 for a 50-minute therapy session - and those numbers are Tucson numbers. 

The insurance barriers are common to both psychiatrists and counselors, most notably the low level of reimbursement and the limited number of sessions. So much for the Mental Health Parity Act (now known as the Mental Health Parity and Addiction Equity Act).

All of this has led to the medical model taking over mental health. The DSM is written mostly by psychiatrists (a large percentage of whom also work for the pharmaceutical industry) and because of this it has become a manual oriented toward diagnoses for which there are pharmaceutical treatments.

This is from the Citizens Commission on Human Rights International:

A study by Dr. Lisa Cosgrove, Ph.D., from the University of Massachusetts, Boston and Harvard Medical School’s Dr. Harold Bursztjanin showed that despite the APA instituting a disclosure policy for DSM-V (due out in 2012), only 8 out of 27 members of the DSM Task Force had no industry relationship. “The fact that 70% of the task force members have reported direct industry ties—an increase of 14% over the percentage of DSM-IV task force members who had industry ties—shows that disclosure policies alone…are not enough and that more specific safeguards are needed,” stated Dr. Cosgrove.  Further, “pharmaceutical companies have a vested interest in the structure and content of DSM, and in how the symptomology is revised.”

 It always comes down to the money.

The result, however, is a diagnostic manual most of the therapists and counselors I know would rather not use - in fact, most of us loathe it. Not only is it cumbersome and frequently contradictory, but it does not accurately reflect what we see in our clients.

Toward a New Diagnostic Manual of Mental Illness

A few days ago I posted an article from Neuroskeptic called DSM-5 R.I.P? over at Facebook. I added a comment, "the DSM is crap - create a diagnostic model based on attachment and other interpersonal elements and we might have something useful," when I posted the article.

A friend asked about my comment and the following discussion ensued. I have edited my comments for clarity and expanded a little where necessary. My comments are the seeds of what I would like to see as an alternate diagnostic manual for clinicians of all kinds - counselors, social workers, marriage and family therapists, and psychologists.

Charlotte: "a diagnostic model based on attachment and other interpersonal elements" ~ Has writing on this in some way begun? And begun to be collected together?

Me: The Norton Series on Interpersonal Neurobiology is probably the closest thing we have to a body of work - and there are a couple of assessment tools for attachment . . . but there is nothing as organized as the DSM.

Charlotte: Of course not as organized and well known as the DSM, but possibly in a beginning form, which is why I wrote "in some way begun." Anything else you think is relevant to an alternative diagnostic model in addition to the Norton Series on Interpersonal Neurobiology and a couple of assessment tools for attachment?

Me: I think a solid foundation in intersubjective systems theory (Stolorow, Orange, Atwood, Brandchaft, and their group) is essential

I think one of the most important issues would be to create some kind of discipline devoted explicitly to how traumas (big-T traumas like abuse, molestation, serious illness, neglect, etc - and small-t traumas like empathic failures, teasing, rejection, and so on) create splitting in the personality - what we generally refer to as subpersonalities or parts. There are many good models (Internal Family Systems, Ego States, Dialogical Self Theory, Psychosynthesis, Voice Dialogue, Gestalt, etc.) that work with parts but we need to look at all of these models and generate a more comprehensive model for how this happens.

I think Allen Schore's work with affect regulation, attachment, right brain development, and therapeutic intervention is a crucial piece. A couple of great articles to read by Schore would be Relational Trauma and the Developing Right Brain: The Neurobiology of Broken Attachment Bonds, The effects of relational trauma on right brain development, affect regulation, and infant mental health, and The Right Brain Implicit Self: A Central Mechanism of the Psychotherapy Change Process.

If we could develop a model that incorporates attachment theory, affect regulation, trauma response, and splitting into a comprehensive diagnostic model, we would have something much more effective and useful than the DSM.




[Not in original comments: Attachment theory really offers us an outstanding model for how to conceptualize the failures in caregiver bonding that result in emotional dysfunction. Allan Schore's Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development (1994), Daniel Stern's The Interpersonal World Of The Infant A View From Psychoanalysis And Developmental Psychology (2000) and Daniel Siegel's The Developing Mind, Second Edition: How Relationships and the Brain Interact to Shape Who We Are (2012), all offer a coherent model for how attachment experiences shape brain development and behavior.

I would also highly recommend David Wallin's Attachment in Psychotherapy (2007), Robert Muller's Trauma and the Avoidant Client: Attachment-Based Strategies for Healing (Norton Professional Books) (2010), and Healing Trauma: Attachment, Mind, Body, and Brain (2003), edited by Dan Siegel and Marion Solomon.

I own and have read all six of these books - they inform a great deal of how I conceptualize cases.]

I use the DSM because I have to - but I conceptualize the issues my clients face in terms of the materials I suggest here.

For example, if I see a client dealing with agoraphobia, I am probably going to begin my conceptualization with anxious attachment and then look at the parental style, which often seems to feature a primary care-giver with primary narcissism, which is normal in infants and toddlers but is a defense mechanism in adults [it might also be some other personality disorder - all personality disorders are based in attachment failures - see Personality disorders as disorganisation of attachment and affect regulation by Sarkar and Adshead - and someone how never experienced secure attachment cannot provide secure attachment].

The client likely never received any consistent mirroring or twinship (terms from Kohut's Self Psychology for how children bond - a fair overview of Kohut's model is here) which leaves the child in a constant state of anxiety around getting affection and getting needs met. We'll also look at the various traumas and/or empathic failures that reinforced that anxiety so that it reached a point where leaving the house was intolerable.

I do think this is the future of psychotherapy. Despite the restrictions of managed care, here are more and more people trying to work this way. I am not aware of anyone trying to create a complete diagnostic model based on these ideas. Yet . . . .