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Chapter Two - Controversies of Process: The DSM and the Pharmaceutical Industry

Rachel Cooper Karnac Books ePub

Whenever a new condition is included in the DSM, or diagnostic boundaries are expanded, a new market for drugs is potentially created. The pharmaceutical industry thus has huge amounts at stake when the DSM is revised. Given that the DSM matters to the pharmaceutical companies, and given that these companies are rich and powerful, there is cause to monitor links between the drugs industry, the APA, and the DSM.

Let's start with the money. A substantial proportion of the APA's revenue comes from pharmaceutical companies (in 2005, $18 million of a total revenue of $61, down to about $7 million of $46 million by 2011) (APA, 2005, 2012a, 2012b). This money comes partly from advertising in APA journals, partly from sponsorship of the annual meeting, and partly through grants for “education, advocacy and research” (APA, 2012a). Other medical specialties also have links with the pharmaceutical industry, and concern about potential conflicts of interest has become widespread (Kaplan, 2008). In line with actions taken by the professional bodies of other medical specialties, in recent years the APA has sought to institute a range of measures aimed at reducing and managing conflicts of interest (Kaplan, 2008). By 2009, drug money going into the APA had significantly declined (both as the APA set out to reduce the number of industry sponsored symposia at its meetings and as the economic downturn reduced advertising revenue) (Cassels, 2010). In addition to general concerns about the APA being so heavily reliant on funding from the pharmaceutical industry, there are more specific worries about links between industry and members of the committees revising the DSM. Individual committee members may have links with industry, such as receiving fees for speaking and consulting, receiving research grants, and having company shares. Many worry that such industry ties might influence committee members.

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CHAPTER FOUR Issues of content: the birth of a new diagnosis—hoarding disorder

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CHAPTER FOUR

Issues of content: the birth of a new diagnosis—hoarding disorder

T

his chapter focuses on one of the new additions to the

DSM-5 that has garnered the least discussion. It will act as an illustration of how changes to the DSM come about, what impact they may have, and how even the least controversial of them can be problematic.

Hoarding disorder is included as a separate disorder for the first time in the DSM-5. In the DSM-IV, hoarding is mentioned only as a possible symptom of obsessive-personality disorder.

The campaign to have hoarding upgraded to a recognised distinct disorder started some time ago. In 1996, a key researcher in the area, Randy Frost, together with Tamara Hartl, published a paper on hoarding that included criteria for the disorder’s diagnosis. They suggested that clinical compulsive hoarding might be defined on the basis of

(1) the acquisition of, and failure to discard, a large number of possessions that appear to be useless or of limited value; (2) living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed; and (3) significant distress or impairment in functioning caused by the hoarding. (Frost & Hartl, 1996, p. 341)

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Chapter Seven - The Future

Rachel Cooper Karnac Books ePub

Throughout this book I have shown how the DSM currently matters hugely. Even small changes can affect the lives of millions. In this last chapter, I look to the future. I shall explain why it is that I think the current dominance of the DSM is by no means guaranteed to continue. In looking ahead, the key point to bear in mind is that we should not assume that the DSM will long continue to exist in anything like its current form.

At the outset, it is worth noting that is likely that the DSM-5 will be the last time that the DSM comes to be revised all in one go and published in book form. The system for numbering volumes has been shifted to facilitate the publication of more regular smaller-scale revisions as and when needed. Rather than DSM-6 being published in 2030, we will have DSM 5.1, DSM 5.2, and maybe DSM 5.3.2.7 (Brauser, 2011; Verhoeff, 2010). This is all to the good. As mentioned previously, the current system meant that important copy editing errors in DSM-IV only came to be revised six years later. A process that allows for more frequent and easier updating can only be a good thing.

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Chapter One - DSM-5: An Overview of Changes

Rachel Cooper Karnac Books ePub

These days, as soon as one edition of the DSM goes to press, work on the next begins. The revision process that culminated in the publication of DSM-5 thus started long ago; with pipe dreams that finally came to nothing. An early publication, A Research Agenda for DSM-V (the Latin numerals only changed later) set out the ambitions (Kupfer, First, & Regier, 2002). A Research Agenda for DSM-V is an extraordinary document. The book doesn't consist of plans for DSM-5 but rather of plans for plans; a series of “white papers” outline research priorities in various areas relevant to psychiatric classification. It is a testament to the phenomenal success of the DSM that such a book should be published, and not only published but published in paperback; research proposals related to psychiatric classification now find a mass readership. The very term “white paper”, used by the editors to describe the chapters, is more normally associated with plans produced by the offices of nation states. Though partly bluster, such self-importance is basically justified. Given that millions of people worldwide suffer from mental disorders, and that the DSM diagnosis someone receives can determine whether and how they are treated, changes to the DSM can potentially affect the lives of as many people as changes in the policies of most countries.

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CHAPTER SIX The field trials: DSM-5 and the new crisis of reliability

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CHAPTER SIX

The field trials: DSM-5 and the new crisis of reliability

A

t time of writing, the DSM-5 has only just been published, and studies showing what differences the revisions have made to clinical practice, research, or service provision, are unavailable. The DSM-5 field trials are currently the best estimators of likely effects. This chapter focuses on one particular issue that has become controversial following the field trials: reliability.

The diagnosis that a patient receives should depend on the symptoms, rather than on who does the diagnosing. Suppose a patient sees a clinical social worker in the United States and is judged to have schizophrenia. If a reliable classification system is used then it should enable, say, a psychiatrist in Kenya, to decide on the same diagnosis.

When the DSM-III was published in 1980, it was presented as solving the problem of ensuring diagnostic reliability (APA,

1980, pp. 467–472). The story told was that while in the dark days of psychoanalytic dominance a patient judged neurotic by one therapist might well appear psychotic or normal to another, with the employment of the DSM-III patients could expect to be given the same diagnosis by all clinicians. Proof of

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