DSM-V Prelude

No, it's not a new concept car from Detroit.  It is a website
that is designed to collect suggestions for the next edition of the
Diagnostical and Statistical Manual (DSM-V).  It occurred to me to mention it
here, after reading a recent article in Seed
magazine.

href="http://www.seedmagazine.com/news/2006/06/serenity_now.php">Serenity
Now!, written by href="http://www.seedmagazine.com/news/author-stu-hutson/">Stu
Hutson, posted on href="http://www.seedmagazine.com/news/2006/06/">June 8,
2006 12:14 AM, is in the category href="http://www.seedmagazine.com/news/brain-behavior/">Brain
& Behavior.

Serenity Now happens to be about the same thing as href="http://scienceblogs.com/corpuscallosum/2006/06/whats_all_the_blather_about_ro_1.php">my
first post here: Intermittent Explosive Disorder.



Mr. Hutson reports that many people are skeptical about the diagnosis.
 One of my commenters agrees.  In fact, I agree too.
 I think it ought to be in the chapter in the back of DSM-IV,
which is reserved for proposed diagnoses that need
further study in order to be included in the main text.  But I
am not ready to dismiss it entirely, either.  More below the
fold...

As I mentioned in my first post, there were differences between the way
the diagnosis was made in the National Comorbidity Survey Replication,
and the way it is defined in DSM.  What that means is that the
NCSR data have to be interpreted carefully, if one plans to use those
data to say anything about what is in the DSM.  



The NSCR data seem to indicate that IED is more common than previously
thought.  That is important, because if the condition really
is common, then it would be worthwhile to devote more resources to
study it.  But the NCSR was not really designed to identify
cases of IED, so the authors have not really established that IED -- as
defined in DSM -- is all that common.  What they have shown is
that a collection of symptoms that resembles IED is
fairly common.  



Despite that technicality, I am not fully on board with the IED
skeptics, either.  It appears that their skepticism is based
on a number of potential issues:



1. Everybody gets angry sometimes.  It is stupid to
call anger a disorder.  My response: everyone has a
heartbeat too.  Does that mean that arrhythmias are not
disorders?



2. People might use it as an excuse.
 My response: people might use anything as
an excuse.   Perpetrators of domestic violence already have a
list of excuses as long as the Tour de France.
 Adding one more to the list won't change anything.



3. Lawyers will try to use it as a defense in legal
cases.  See #2.  Plus, lawyers might use genetics
as a defense.  Should we stop studying genetics?



4. Violent people don't need treatment, they need punishment.
 My response: those are two separate issues.  The
courts make decisions about punishment.  Doctors make
decisions about treatment.  American military doctors in Iraq
treat wounded insurgents.  Who are we to tell them to stop?
 You may think they shouldn't provide that treatment, and you
are entitled to your opinion, but it is not your decision to make.
 You may have the opinion that violent people should not get
treatment, but again, that is not your decision to make.



5. Doctors might use it as a pretext to give medications.
 My response: huh?  Like we don't
have anything better to do than go around finding people who don't need
treatment, and treating them anyway?  I can assure you, there
is plenty of illness out there to be treated.  Nobody needs to
(or wants to) waste resources treating people who are not in need of
treatment, or who clearly cannot benefit from treatment.



On the other hand, I suppose there are some unscrupulous doctors out
there who might apply treatments indiscriminantly, but I would like to
think it is a small minority.  



6. It just doesn't seem reasonable to think of it as a disease.
 My response: up until the 1980's most psychiatrists did not
think it was reasonable to think of posttraumatic stress disorder as a
disease.  Now, the neurobiology is href="http://trots.blogspot.com/2004/07/ptsd-among-american-service-personnel.html">becoming
clear (scroll to the bottom for the relevant part), and
virtually all psychiatrists think it is a valid diagnosis.  



7. If we don't understand it, we should not try to treat it.
 This was mentioned in the Seed article:

"We don't immediately know what causes the problems
in our heads," he continued, "so we shouldn't dole out knee-jerk
medications as if we did—especially not when counseling or
rooting out a life problem will do the trick."

My responses: if we waited until we fully understood the problem before
trying to treat it, we would never treat anything, and there would be
no progress in medical science.  Many, if not most, medical
decisions are made in the absence of a full understanding.
 Anyone who thinks they "know what causes the problems in our
heads" is sadly mistaken.  There are something like 10¹⁵
synaptic connections in a human brain.  There are dozens of
neurotransmitters.  We probably don't even know all of them.
 The brain is the most complex organ in the body.  It
is the most complex entity in the known universe.  Don't tell
me anyone knows what is going on inside it.  That's nonsense.
 



Plus, treatment with counseling is not a priori
better (or worse) than treatment with medication.  You have to
fit the treatment to the condition and to the patient.  As for
rooting out life problems, well, I think we can agree that would be the
best solution, if it is possible.  But not everyone can go out
and get a new job, or new spouse, or whatever.  



So, back to the DSM-V Prelude.  People who want to have input
into the revision of DSM-IV can href="http://www.dsm5.org/suggestions.cfm">go there
to make suggestions.  If you can make a case that IED should
be dropped, go for it.  But you have to register first, and
provide contact information.  They expect to see a
carefully-reasoned argument, preferably with references and data
attached.  Don't just go over there and start ranting.
 They might put you on some kind of medication.