Diagnostic and Statistical Manual of Mental Disorders (DSM – Manual de Diagnostic si Statistica ale Tulburarilor Mentale

In Romania, a country of the European Union, there is an epidemic of measles disease that has been declared by WHO many years ago eradicated in Europe!

There are 17 dead measles children and six thousand children and infected adults!

Thus, measles spread throughout Europe, and even Germany, which reported about 400 cases, took severe measures to stop the spread of the disease by refusing 2500 euros to those who refused to vaccinate.

Why does the mental illness suffer those people who refuse to vaccinate their children?

Is the refusal to vaccinate a mental illness, a complex of superiority derived from the so-called information on the Internet, that is, from reading fake news?

Can the DSM answer these questions?

Let's see what DSM is:

"It is easy to criticize, Kapur says, but" I think many people do not know history at all, because they can find any defect for DSM, but they do not know anything about the confusion that reigned about the diagnosis of psychiatric disorders 40 years ago ... What was called schizophrenia in New York was not schizophrenia in London, and from this point of view I made a huge leap. "

 Jonathan Gornall Independent Journalist, Suffolk, UK

jgornall@mac.com

No interests declared.

Provenance and peer review: Requested article; Without external evaluation.

The bibliography is found in the bmj.com version

 Translation: Dr. Rodica Chirculescu

”DSM-5: a fatal diagnosis?
Posted by BMJ.RO on Thursday, 12/05/2013 - 11:14
The pre-launch period of the DSM-5 has been marked by criticism of an unprecedented level. Jonathan Gornall wonders if the US psychiatric influential manual has eventually become an exaggeration
 It does not happen every day that a new medical manual attracts to such an extent the attention of the media, as if it were the last novel blockbuster of a world-famous author. The controversy that has begun around May 22 to launch the long-awaited edition of the long-awaited Diagnostic and Statistical Manual of Mental Disorders has expanded to an international scale, Rivaling with the advent of Dan Brown's latest thriller. And although DSM-5 and Inferno - a dynamic evolution among the pointers taken from the 14th century Dante Alighieri poem, Divine Comedy - have no literal tangency, it brings them closer to the fact that the authors of both works have gone through hell In the hands of critics.
The American Psychiatric Association (American Psychiatric Association) developed the first DSM in 1952, and in the 60 years since then there have been six iterations. The last was a review of the DSM-IV text of 1994, published as DSM-IV-TR in 2000, which means that the DSM-5 (Roman figures abandoned for this last edition, respecting the requirements of the digital age) Was developed in 13 years of cranny fights, in which the decision-makers were under the guise of unprecedented checks and attacks.
During its first decades of existence, DSM was not too much in the public eye, although one of the germs of dissatisfaction now came to paroxysm - that is, the suggestion that the International Classification of Diseases (ICD - International Statistical Classification of Diseases and Related Health Problems ) Of the World Health Organization (WHO) is the only manual currently needed in the world of psychiatry and psychotherapy - since the birth of DSM in 1952.
In 1948, the WHO drafted the sixth edition of the ICD, which included for the first time a category for mental disorders. Although it was largely deduced from the US Veterans Administration experience and the classification of mental disorders developed while working with World War II military personnel, the American Nomenclature and Statistics Committee The Psychiatric Association has decided to develop its own manual1, 2
DSM came to the attention of the press in 1973 when members of the American Psychiatric Association, who initiated the review process needed to develop DSM-III, began to deliberate whether homosexuality should or may not be "removed from the official mental association catalog of the association" Which was referred to as a "sexual deviation," with sadism and masochism.3
Among those who agreed to eliminate it was Robert Spitzer, the man who, as chairman of the DSM-III working group in 1980, is almost unanimously accepted as a modern DSM architect and disease classification in the manual. It seems, however, that later, Spitzer has changed his mind about psychiatric abstinence crystallized in the DSM-III - and his reserves, expressed six years ago, sparked wide echoes among contemporary critics of the DSM-5.
Medical experience of ordinary experiences
In a 2007 BBC documentary, Spitzer said, "We have made estimates of the prevalence of purely descriptive medical disorders, without taking into account that many of these conditions may be normal reactions, which are not, in fact, disorders, because they are not We were interested in the context in which these conditions developed. "4 And admitted that," to a certain extent, "they medicated much of the" ordinary states of people, such as sadness or fear. "
It is one of the main criticisms of the DSM-55 version - and only a few were formulated with the eloquence of Frank Farley, the former president of the American Psychological Association, who perceives a personal offending blame for removing a DSM-5 clause Exclusion that avoids diagnosing doli as a major depressive disorder in the first two months after the death of a loved one.
"Grief is normal," he says, "and if you are excited for more than two months you should be labeled with a kind of mental illness - and this will be the terminology used by the public? The answer is clear, no. My first wife died three decades ago; I do not suffer for a long time after she died, but I think about it now, and my memories are causing me emotions. There is nothing wrong with human nature. "
Farley, like many other critics, is concerned about the contribution of DSM-5 to what he calls "implacable production of disorders and the pathology of normal extremes." 6
In his opinion, however, it remains true that psychiatry and psychology in general must be "better connected with the real world. I'm worried that we have too much monastic science in us; Too many laboratory studies. People do not live, do not get mad and do not feel the pain in the labs. "
The American Psychiatric Association (APA), who has been invited to criticism and contributions during the long review process and has received an unprecedented 15,000 comments since 2010, has consistently defended its position. But his defense of the elimination of "mourning exclusion," written by a member of the DSM-5 mood disorder group, seems to confirm the greater fears that the system of the Association's coordinating committee for selecting disorders for inclusion is A recipe for escalating disorders.
Kenneth Kendler, of the Virginia Institute for Psychiatric and Behavioral Genetics, wrote in a document posted on the 2011 APA website, added to DSM-III "largely on the basis of the experience of one of its members Working group for DSM-III, who then studied mourning, being maintained with minimal changes in the DSM-IV. "8
Favorable interests
Peter Tyrer, a professor of community psychiatry at Imperial College London and editor of the British Journal of Psychiatry, is the chair of the personality disorder group to review the ICD-11, scheduled to appear in 2015. In his opinion, A very good example of what I think is wrong with DSM. More smart people sit around the table and say, 'We've worked on this issue and I want to include the narcissistic personality disorder,' 'I want to have disocial personality disorder,' 'I want to have an avoidable personality disorder.
In fact, he says, "these are categories of unruly personality disorder, in fact, of no scientific basis, and yet how all the respectable members of the committees agree that they are important and that we have to include them." The result, Says Tyrer, is that "we are in danger of medicating unnecessary people."
While admitting that the ICD, with its poorer resources, "followed the example" offered by DSM, Tyrer is not the only one who believes that while the situation created "was a stimulus to the interest in classification," DSM Become an exaggeration and, in front of a consolidated, streamlined ICD, is now about to be "eliminated."
"I think there are disorders that are the favorites of doctors or physician groups," said Gary Greenberg, a Connecticut psychotherapist and author of The Book of Woe-The DSM and the Unmaking of Psychiatry, published recently.
"I intend to introduce [a disorder] into DSM and succeed, in part, because they are the people in the committee."
In this regard, he points out, the best example of DSM-5 is affective disorder with disruptive disorder, one of a series of new depressive disorders. It was introduced, says APA, "to address concerns about the potential diagnosis and excessive treatment of bipolar disorder in children." 10
Other newly introduced elements include the excoriation disorder, for which there is "strong evidence in support of the clinical validity and clinical utility of the diagnosis," the trembling disorder, "which reflects persistent difficulties in giving up or sharing, generated by the perceived need To keep things and the distress associated with giving up. "10
Curiously, one of the most overwhelming critics of the DSM-5 process was Allen Frances, chair of the DSM-IV working group. Since 2010, its unfriendly arrows, thrown out of the articles published in Psychology Today, have targeted everything from $ 199 (130 ₤; 155 €) to the DSM's "robbery price," to the suggestion that the manual "will offer Pharmaceutical companies a good ground to continue their undesirable interests about sexual disorders in women. "11 12
He joined various circles of opponents, including the Society for Humanistic Psychology, which began a public debate in January 2012 by sending an open letter to the DSM-5 working group, asking them to submit their proposals to a group Independent of experts. The letter was supported by an online petition that drew the signatures of over 14,000 people and 53 organizations, including the British Psychological Society. 13, 14
"There is talk of a kind of anxious to express ourselves gently," Farley said, "and basically, thank you, but no, thank you. He argues that, through expertise, scientific information is well supported. "
Internal disagreements
There was no consensus within the working group. Last April, two members of the DSM-5 Personality Disorder Working Group quit their activity, claiming that the team had been overlooked "an important opportunity to deepen the study of personality disorders through The development of a evidence-based classification with a greater clinical utility than DSM-IV, "being instead advanced by" a truly astonishing disregard of evidence, "a" gravely vicious "proposal that was" useless, incoherent And inconsistency. "
In an e-mail made public by Frances, Roel Verheul and John Livesley wrote that some important aspects of the proposal were not supported by any "reasonable evidence of trust and validity." Not surprisingly, in their opinion, The proposal has received many criticisms, but the group has remained impenetrable. "
Verheu, a professor of personality disorders at the Viersprong Institute in Amsterdam, and Livesley, former head of the psychiatric department at the University of British Columbia, were the only members of the original group in another country and were labeled by Frances as a " A small group of 'experts' of the DSM-5 ruined by the world, who ignore the harsh criticism from the inside and the almost universal rejection of their proposals by all the other specialists in the field.
 Conflicts of interest
One of the worst accusations against DSM is that the main manual psychiatrists have been influenced by the pharmaceutical-related relationship, 16 but the APA has retained their share. Although David Kupfer, a professor of psychiatry at the University of Pittsburgh and chair of the DSM-5 working group, was "expected" to speculate, in a January press release, "it is important to recognize that APA has taken great steps to ensure that DSM-5 and APA clinical practice guidelines are not influenced and biased. "
The steps taken, Kupfer reported for Medscape in January, included limiting annual pharmaceutical income for members of the working group to a maximum of $ 10,000 for each and holding shares in drug companies worth less than $ 50,000 - "Stricter than those imposed on staff from the National Institutes of Health, for members of the Food and Drug Administration (FDA) and for most departments."
But the theories of corruption-conspiracy lose sight of the essence, says Greenberg, who thinks it is a "confederation of good intentions" at work. "DSM is created by committees, which is one of the reasons that transforms it into a" A heavy document, and the committees are made up of experts in the field, who tend to be valued and tracked by pharmaceutical firms to carry out their research.
"I do not feel the immense conspiracy - it's not like pharmaceutical companies would say to a psychiatrist," Look, we could even use this disorder in DSM, so here's fifty thousand. "There's no need, because we have an entire profession Intellectually predisposed to see mental problems as problems requiring medical treatment. "
However, it has not served the cause of DSM or American psychiatry in general that, since 2008, Senator Charles Grassley, chairman of the US Senate Finance Committee, has stunned a number of cases where senior psychiatrists Have revealed important payments from pharmaceutical companies.
One of the most widely publicized cases was that of Charles Nemeroff, who resigned in 2008 from the post of head of the department of psychiatry at Emory University, Atlanta, after being told he did not report over 1.2 million $ Awarded by GlaxoSmithKline, although he had signed a commitment to limit his payments to $ 10,000 a year, and worked as a senior investigator in a study by the National Institutes of Health on the company's antidepressant medications.18-21 In 2009, Nemeroff was named the boss Psychiatric department at the University of Miami.
Challenges from biology
A stronger blow for the future of DSM was recently given by the National Institute of Mental Health (NIMH) in the United States, which launched an unexpected attack on DSM, criticizing its "lack of validity "And announcing that it" is reorienting its [research funding] outside the DSM categories "and in establishing a new classification system based on both biology and symptoms of mental disorders.
The Research Domain Criteria Project (RDoC), recently said Thomas Insel, director of NIMH, was "only a plan to transform clinical practice by conducting new research to get information on how we diagnose and treat mental disorders. "
The future of long-term mental health, he said, lies in the discovery of biomarkers: "Unlike the definitions of ischemic heart disease or AIDS-related lymphoma, DSM diagnostics are based on a consensus on clusters of clinical symptoms rather than on any objective determination Laboratory. "
Beginning practically from scratch, RDoC is, for the time being, a far too distant challenge to gain supremacy from DSM. "It is the way forward, but nowhere is it located in the proximity of a framework suitable for its application in order to create a diagnostic system," said Shitij Kapur, dean of the Institute of Psychiatry at King's College London and author of an article published last year, Examining the reasons why biological psychiatry took so long to reach clinical trials.23
For the time being, he says, "we have a work to do, and [ICD and DSM] are the tools we have." The differences between them "are, in 95% of cases, irrelevant or just for connoisseurs," and Reality is the question "does the world need a DSM and an ICD?"
Kapur believes that the new DSM's agitation "will completely dissipate, because the DSM-5 is not a revolution; Only if it's a sensible improvement. There are people who are disappointed because 10 years ago we were hoping to have clear biological tests and the new DSM will radically review all the deficiencies we have in psychiatric disorders. "
He argues that it is not too simplistic to characterize DSM-related controversy as psychiatry versus psychotherapy or medication versus word therapy, and that camps have "elicited" tensions amid the launch of DSM.
"That does not mean that the tensions are real or important, but that they were not born yesterday, and the DSM-5 does not necessarily make them worse or worse."
The influence of DSM in the UK
On June 4, King's College Institute of Psychiatry hosted a two-day international conference on DSM-5 and the "Future of Psychiatric Diagnosis." Although the UK is using ICD, Kapur argues that it would be a mistake to assume that DSM Has no effect on British psychiatry.
"It would not be wise for the rest of the world to ignore the things happening in the US because there is, without a doubt, the center of academic and professional power in psychiatry, there are so many concepts, ideas, discoveries and almost 10 times More articles than any other country, "he says.
When it comes to scientific discourse, adds Kapur, DSM has a "ascendant" on DCI: a British psychiatrist treating a schizophrenic patient will most likely read thematic articles whose subjects had been diagnosed by DSM doctors.
As editor of the British Journal of Psychiatry, Tyrer says he regularly reminds US authors that "the UK is among the last regions of the world where there is no DSM, because we have not been influenced by the significant sales of DSM."
However, the statement that 'this person has a DSM diagnosis of major depression' has more weight than if it were said that 'this person has an ICD diagnosis of mild depressive illness.' "
The above has been demonstrated by an important British trial in 2005 in which a man accused of having spent his parents spending money spending money on credit cards avoided a conviction for murder by admitting The murder of a diminished responsibility based on the fact that it had a narcissistic personality.24 The disorder occurs only in DSM: "Narcissism has never been in the ICD classification and I'm sure it will not be," Tyrer said. "It is a diagnosis of vanity for both patients and their doctors."
 DSM defense
One of the participants in the DSM-5 conference is David Kupfer, chair of the DSM-5 working group; He is firmly convinced that the UK deserves a visit right after the publication of the book - at a time that, for its part, will surely be frenetic - and leaves little to the impression of a man sitting on a diabolical chair Hot.
One of the key messages he is willing to convey is that the DSM-5 remains "the best science available and the most useful manual for patient care clinics" - and, surprisingly, does not accept the idea that DSM should cede Place of ICD.
"DSM and ICD can be considered a pair," says Kupfer. "They are correlated, so a clinician using the DSM can use the ICD diagnostic coding system required in most health systems in the world. It is important to remember that ICD does not include descriptive diagnostic criteria, but only a list of disorders. DSM-5 is the best clinical guide to diagnosing mental disorders. "
Similarly, in spite of the vehemence of the NIMH attack on DSM, he insists that "DSM-5 and RDoC of the National Institute are complementary, not competitive work cadres. Once the RDoC's efforts are outlined, any information or feature resulting from its research agenda will be integrated into the upcoming editions of the DSM to strengthen patient assistance. "
Kupfer bypassed the answer to the question of the difficulty of having his predecessor as DSM-IV president as the most invisible critic of the DSM-5.
"Although it is mandatory to argue and criticize," he said, "we believe it is important to remain focused on the fact that the DSM-5 has been developed over a decade, benefiting from the competition of at least 1 500 of the best Experts in the field and synthesis in extenso from the specialty literature, original researches and trials at national scale. "
Of course, those trials also provoked controversy. For Farley and others, they just showed that "science [at the base of the DSM-5] is not good enough."
Between November 2010 and November 2012, the DSM-5 criteria for 23 disorders were tested by hundreds of psychiatrists who worked with 3,500 patients nationwide. According to the APA, six diagnoses "had relatively low trust scores, a fact that is considered questionable but acceptable in the report"; Among them were two of the most common diagnoses in DSM: major depressive disorder and generalized anxiety disorder.
Legislative Threats
At present, all debates about what should and should not be included in DSM-5 take place at the academic level. It may, however, be that the future of the manual is more threatened in the form of mandatory cross-border migration from ICD-9 to ICD-10 codes in October 2014 for all health care providers targeted by the US Health Insurance Portability and Accountability Act (HIPAA), which enters into the Medicare national insurance program and Medicaid, a health program testing the funds for eligibility.
As with ICD-9, the US modified the ICD-10 to use it in its own medical system, but the distinction is that for the first time ICD-10-CM will push many psychiatrists and psychologists out of the DSM.
"Currently, many psychologists use DSM-IV-TR when diagnosing patients and the corresponding DSM-IV-TR codes to make a medical insurance claim," the psychiatric association said in an update to its members in February. This was OK for ICD-9 because its diagnostic codes were aligned with those of the DSM, but the ICD-10 codes will be different and "anyone who will register DSM codes instead of ICD-10-CM can assume that Risk responding to the refusal of payment. "26
It is easy to criticize, Kapur says, but "I think many people do not know history at all, because they can find any defect for DSM, but I do not know anything about the confusion that reigned about the diagnosis of psychiatric disorders 40 years ago. Called schizophrenia in New York was not schizophrenia in London, and from this point of view I made a huge leap. "
 Jonathan Gornall Independent Journalist, Suffolk, UK
jgornall@mac.com
No interests declared.
Provenance and peer review: Requested article; Without external evaluation.
The bibliography is found in the bmj.com version
 Translation: Dr. Rodica Chirculescu
from:
http://www.bmj.ro/articles/2013/12/05/dsm-5-un-diagnostic-fatal
 

În România ,țară a Uniunii Europene există o epidemie de rujeolă boală care a fost declarată de OMS cu mulți ani în urmă eradicată în Europa!

Asăzi când vorbim există 17 de copii morți de rujeolă și șase mii de copii și adulți infectați!

Astfel rujeola s-a răspândit în Europa iar până și Germania care a raportat aproximativ 400 de cazuri a luat măsuri severe ca să oprească răspândirea bolii amendând cu 2500 de euro pe cei care refuză vaccinarea.

De ce boală psihică suferă acei oameni care refuză să-și vaccineze copii?

Este refuzul de a se vaccina o boală psihică ,un complex de superioritate derivat din așa zisa informare de pe internet adică din citirea știrilor false?

Poate DSM să răspundă la aceste întrebări?

Să vedem ce este DSM:

”Este usor de criticat, spune Kapur, dar “cred ca multi oameni nu cunosc deloc istoria, fiindca pot gasi orice defect pentru DSM, dar nu stiu nimic despre confuzia ce domnea in privinta diagnosticarii tulburarilor psihiatrice in urma cu 40 de ani... Ce se numea schizofrenie in New York nu era schizofrenie in Londra, iar din acest punct de vedere am facut un salt urias.”

 Jonathan Gornall jurnalist independent, Suffolk, Marea Britanie

jgornall@mac.com

Competing interests: Niciunul de declarat.

Provenance and peer review: Articol solicitat; fara evaluare externa.

Bibliografia se gaseste in versiunea de pe bmj.com

 Traducere: Dr. Rodica Chirculescu

”DSM-5: un diagnostic fatal?
Trimis de BMJ.RO la Joi, 12/05/2013 - 11:14
Perioada premergatoare lansarii DSM-5 a fost marcata de critici de un nivel fara precedent. Jonathan Gornall se intreaba daca nu cumva influentul manual de psihiatrie american a ajuns, pana la urma, o exagerare.
Nu se intampla in fiecare zi ca un nou manual medical sa atraga intr-o masura atat de mare atentia mass-mediei, de parca ar fi fost ultimul roman blockbuster al unui autor de faima mondiala. Controversele starnite, in preajma datei de 22 mai, de lansarea celei de-a cincea editii a Diagnostic and Statistical Manual of Mental Disorders (DSM – Manual de Diagnostic si Statistica ale Tulburarilor Mentale), indelung asteptata, s-au extins la scara internationala, rivalizand cu aparitia celui mai recent thriller al lui Dan Brown. Si, cu toate ca DSM-5 si Inferno – o dinamica evolutie printre indicii preluate din poemul lui Dante Alighieri din secolul XIV, Divina Comedie – nu au nicio tangenta din punct de vedere literar, le apropie faptul ca autorii ambelor lucrari au trecut prin iad in mainile criticilor.
American Psychiatric Association (Asociatia Psihiatrica Americana) a elaborat primul DSM in 1952, iar in cei 60 de ani de atunci au existat sase iteratii. Ultima a fost o revizuire a textului DSM-IV din 1994, publicat ca DSM-IV-TR in anul 2000, ceea ce inseamna ca DSM-5 (cifrele romane au fost abandonate pentru aceasta ultima editie, din respect pentru cerintele erei digitale) a fost elaborat in 13 ani de lupte crancene, in care decidentii s-au aflat sub tirul unor verificari si atacuri fara precedent.
In timpul primelor sale decenii de existenta, DSM nu s-a situat prea mult in vazul publicului, desi unul dintre germenii nemultumirii ajunse acum la paroxism – si anume, sugestia ca International Classification of Diseases (ICD – Clasificarea Internationala Statistica a Bolilor si Problemelor de Sanatate Inrudite) a Organizatiei Mondiale a Sanatatii (OMS) este singurul manual de care are nevoie in prezent lumea psihiatriei si a psihoterapiei – exista inca de la nasterea DSM, in 1952.
In 1948, OMS a elaborat cea de-a sasea editie a ICD, ce a inclus in premiera o categorie pentru tulburarile mentale. Desi a fost dedusa, in mare parte, din experienta US Veterans Administration (Administratia Veteranilor din SUA) si clasificarea tulburarilor mentale s-a dezvoltat in timp ce se lucra cu personalul militar din cel de-al doilea razboi mondial, comitetul pentru nomenclatura si statistica al American Psychiatric Association a decis sa elaboreze propriul manual.1, 2
DSM a aparut in atentia presei in 1973, cand membrii American Psychiatric Association, care au initiat procesul de revizuire necesar elaborarii DSM-III, au inceput deliberarea daca homosexualitatea ar trebui sa fie sau nu “eliminata din catalogul oficial al bolilor mentale al asociatiei,” in care se regasea mentionat ca o “deviatie sexuala,” alaturi de sadism si de masochism.3
Printre cei care au agreat eliminarea ei a fost si Robert Spitzer, omul care, in calitate de presedinte al grupului de lucru ce a elaborat DSM-III in 1980, este aproape unanim acceptat ca architect al DSM modern si al clasificarii bolilor din manual. Se pare insa ca, mult mai tarziu, Spitzer s-a razgandit in privinta abodarii psihiatrice cristalizate in DSM-III – iar rezervele sale, exprimate cu sase ani in urma, au starnit largi ecouri in randul criticilor contemporani ai DSM-5.

Medicalizarea experientelor obisnuite
Intr-un documentar BBC din 2007, Spitzer afirma: “Am realizat estimari ale prevalentei tulburarilor medicale pur descriptiv, fara a lua in considerare faptul ca multe dintre aceste conditii pot fi reactii normale, ce nu sunt, propriu-zis, tulburari, fiindca nu ne interesa contextul in care se dezvolta respectivele conditii.”4 Si admitea ca, “intr-o oarecare masura”, ele au medicalizat mare parte din “starile obisnuite ale oamenilor, precum tristetea sau frica”.
Este una dintre principalele critici aduse versiunii DSM-55 – si doar putine au fost formulate cu elocventa lui Frank Farley, fostul presedinte al American Psychological Association, care percepe ca pe-o ofensa personala blamata decizie de-a elimina din DSM-5 o clauza de excludere ce evita diagnosticarea doliului drept tulburare depresiva majora in primele doua luni dupa decesul unei persoane dragi.
“Intristarea este normala,” afirma el, “si daca esti indurerat mai mult de doua luni ar trebui sa fii etichetat cu un fel de boala mentala – si aceasta va fi terminologia utilizata de public? Raspunsul este clar, nu. Prima mea sotie a decedat in urma cu trei decenii; nu sufar ca in indelungata perioada de timp dupa ce a murit, dar ma gandesc si-acum la ea, iar amintirile imi provoaca emotii. Or, nu e nimic in neregula – asa este natura umana.”
Farley, ca multi alti critici, este preocupat de contributia DSM-5 la ceea ce numeste “implacabila productie de tulburari si patologizarea extremelor normale.”6
Dupa parerea lui, insa, ramane adevarat faptul ca psihiatria si psihologia, in general, trebuie sa fie “mai bine conectate cu lumea reala. Sunt ingrijorat ca avem in noi prea mult din stiinta monastica; prea multe studii de laborator. Oamenii nu traiesc, nu jelesc si nu simt durerea in laboratoare.”
American Psychiatric Association (APA), care a invitat la critica si la contributii pe parcursul lungului proces de revizuire, iar din anul 2010 a primit un numar “fara precedent” de 15 000 de comentarii,7 si-a aparat intotdeauna pozitia cu fermitate. Dar, apararea sa in privinta eliminarii “excluderii legate de doliu,” scrisa de un membru al grupului de lucru pentru  tulburarile de dispozitie din DSM-5, pare sa confirme temerile mai mari ca sistemul comitetului coordonator al asociatiei pentru selectarea tulburarilor in vederea includerii este o reteta pentru escaladarea tulburarilor.
Criteriile de excludere a doliului, scria Kenneth Kendler, de la Virginia Institute for Psychiatric and Behavioural Genetics, intr-un document postat pe website-ul APA in 2011, au fost adaugate la DSM-III “in mare parte pe baza experientei unuia dintre membrii grupului de lucru pentru DSM-III, care studia pe-atunci doliul, fiind mentinute cu minime modificari si in DSM-IV.”8

Interese favorizante
Peter Tyrer, profesor de psihiatrie comunitara la Imperial College London si editor al British Journal of Psychiatry, este presedinte al grupului care se ocupa de tulburarile de personalitate pentru revizuirea ICD-11, programat sa apara in 2015. In opinia lui, domeniul sau ofera “un foarte bun exemplu pentru ceea ce cred ca este in neregula cu DSM. Mai multi oameni destepti stau in jurul mesei si spun ‘Am lucrat pe acesta problematica si vreau sa am inclusa tulburarea de personalitate narcisista,’ ‘Vreau sa am tulburarea de personalitate disociala,’ ‘Eu vreau sa am tulburarea de personalitate evitanta.’”
De fapt, afirma el, “acestea sunt categorii ale tulburarii de personalitate nesustinute, in fond, de nicio baza stiintifica si iata cum, totusi, toti membrii respectabili ai comitetelor cad de acord ca sunt importante si ca trebuie sa le includem.” Rezultatul, spune Tyrer, este ca “suntem in pericol de a medicaliza oamenii inutil.”
Desi admite ca, vreme indelungata, ICD, cu resursele sale sarace, “a urmat exemplul” oferit de DSM, Tyrer nu este singurul care crede ca, in timp ce situatia creata “a fost un stimul pentru interesul legat de clasificare,” DSM a devenit o exagerare si, in fata unui ICD consolidat, eficientizat, este acum pe cale de “a fi eliminat.”
“Sunt de parere ca acolo exista tulburari care sunt favoritele unor doctori sau ale unor grupuri de medici,” afirma Gary Greenberg, un psihoterapeut din Connecticut si autor al volumului The Book of Woe—The DSM and the Unmaking of Psychiatry, publicat recent.9
“Isi propun sa introduca [o tulburare] in DSM si reusesc, in parte, pentru ca ei sunt persoanele din comitet.”
In acest sens, arata el, cel mai bun exemplu din DSM-5 este tulburarea afectiva cu dereglare disruptiva, una dintr-o serie de noi tulburari depresive. A fost introdusa, sustine APA, “pentru a raspunde preocuparilor legate de potentiala diagnosticare si tratare in exces a tulburarii bipolare la copii.”10
Alte elemente recent introduse includ tulburarea cu excoriatie, pentru care exista “dovezi puternice in sprijinul validitatii si utilitatii clinice a diagnosticului,” tulburarea de tezaurizare, “ce reflecta dificultatile persistente de a renunta la posesiuni sau de a le imparti, generate de nevoia perceputa de a pastra lucrurile si de distresul asociat cu renuntarea la ele.”10
Curios, unul dintre cei mai inversunati critici ai procesului implicat de DSM-5 a fost Allen Frances, presedintele grupului de lucru pentru DSM-IV. Din 2010, sagetile sale, deloc prietenoase, aruncate din articolele publicate in Psychology Today, au vizat totul, de la “pretul de jaf” al DSM, 199 $ (130 ₤; 155 €) – si pana la sugestia ca manualul “va oferi companiilor farmaceutice un teren propice pentru a-si continua interesele indezirabile cu privire la tulburarile sexuale la femei.”11  12
El a aderat la diferite cercuri de oponenti, printre care Society for Humanistic Psychology care, in ianuarie 2012, a inceput o dezbatere publica prin trimiterea unei scrisori deschise catre grupul de lucru al DSM-5, solicitandu-i sa-si prezinte propunerile unui grup independent de experti. Scrisoarea a fost sustinuta printr-o petitie online care a atras semnaturile a peste 14 000 de persoane si 53 de organizatii, inclusiv British Psychological Society (Societatea Britanica de Psihologie).13, 14
“Se vorbeste de un soi de neliniste, ca sa ne exprimam bland,” afirma Farley, “si, practic, multumim, dar nu, multumim. Se sustine ca, prin prisma expertizei, informatiile stiintifice sunt bine sustinute.”
 Dezacordurile interne
In cadrul grupului de lucru nu a existat, insa, un consens. In aprilie anul trecut, doi membri ai grupului de lucru pentru tulburarile de personalitate din DSM-5 au renuntat la activitatea pe care o desfasurau, sustinand ca in colectivul respectiv fusese trecut cu vederea “un important prilej de-a aprofunda studiul tulburarilor de personalitate prin elaborarea unei clasificari bazate pe dovezi cu o utilitate clinica mai mare decat DSM-IV,” fiind avansata, in schimb, printr-o “desconsiderare realmente uluitoare a dovezilor,” o propunere “grav viciata”, care era ”inutil de complexa, incoerenta si inconsistenta.”
Intr-un e-mail facut public de Frances, Roel Verheul si John Livesley scriau ca unele aspecte importante ale propunerii nu erau sustinute de niciun fel de “dovezi rezonabile in privinta increderii si a validitatii.” Fapt deloc surprinzator, dupa parerea lor, “propunerea a primit numeroase critici, fata de care grupul de lucru a ramas, insa, impenetrabil.”
Verheul, profesor specializat in tulburarile de personalitate la Viersprong Institute din Amsterdam, si Livesley, fost sef al catedrei de psihiatrie de la University of British Columbia, au fost singurii membri ai grupului originari dintr-o alta tara, fiind etichetati de Frances drept un “mic grup de ’experti’ ai DSM-5 rupti de lume, care ignora cu inversunare criticile taioase venite din interior si aproape universala respingere a propunerilor lor de catre toti ceilalti specialisti in domeniu.”15
 Conflicte de interese
Una dintre cele mai grave acuzatii impotriva DSM este ca principalii psihiatri care au lucrat la manual au fost influentati prin relatiile legate de finantare cu industria farmaceutica,16 dar APA le-a tinut partea. Desi era ”de asteptat” sa apara asemenea speculatii, a afirmat David Kupfer, profesor de psihiatrie la University of Pittsburgh si presedinte al grupului de lucru pentru DSM-5, intr-un comunicat de presa din ianuarie, “este important sa recunoastem faptul ca APA a facut pasi mari pentru a se asigura ca DSM-5 si ghidurile de practica clinica APA nu sunt influentate si partinitoare.”
Pasii facuti, a relatat Kupfer pentru Medscape in ianuarie, au inclus limitarea venitului anual din surse farmaceutice, pentru membrii grupului de lucru, la maximum 10 000 $ pentru fiecare si detinerea de actiuni la companiile de medicamente in valoare de sub 50 000 $ – limite “mai stricte decat cele impuse pentru personalul de la National Institutes of Health (Institutele Nationale de Sanatate), pentru membrii comitetelor consultative pentru Food and Drug Administration (FDA – Agentia Alimentelor si Medicamentelor) si pentru majoritatea departamentelor universitare.”17
Dar teoriile legate de coruptie-conspiratie pierd din vedere esenta, spune Greenberg, care crede ca este vorba de “o confederatie de bune intentii” la lucru.“ DSM este creat de comitete, ceea ce constituie unul dintre motivele ce-l transforma intr-un document greoi, iar comitetele sunt alcatuite din experti in domeniu, care tind sa fie persoane valorizate si urmarite de catre firmele farmaceutice pentru a le realiza cercetarile.
“Nu am senzatia unei imense conspiratii – nu este ca si cum companiile farmaceutice ar spune unui psihiatru, ‘Uite, chiar am putea utiliza aceasta tulburare in DSM, asa ca iata cincizeci de mii.’ Nici nu e nevoie, fiindca avem o intreaga profesie predispusa intelectual sa vada problemele mentale drept probleme ce impun tratament medicamentos.”
Oricum, nu a servit nici cauzei DSM, nici psihiatriei americane, in general, faptul ca, din 2008, senatorul Charles Grassley, presedintele comitetului pentru finante din senatul american, a dezgropat cu incapatanare o serie de cazuri in care psihiatrii aflati la conducerea universitatilor nu au dezvaluit plati importante din partea companiilor farmaceutice.
Unul dintre cazurile cele mai intens mediatizate a fost cel al lui Charles Nemeroff, care a demisionat in 2008 din functia de sef al departamentului de psihiatrie de la Emory University, Atlanta, dupa ce s-a aflat ca nu a raportat sume de peste 1,2 milioane $ acordate de GlaxoSmithKline, desi semnase un angajament pentru limitarea platilor la 10 000 $ pe an si lucra ca investigator principal intr-un studiu al National Institutes of Health pe medicamente antidepresive ale companiei citate.18-21 In 2009, Nemeroff a fost numit seful catedrei de psihiatrie de la University of Miami.
 Provocari din partea biologiei
O si mai puternica lovitura pentru viitorul DSM a fost data recent, insa, de catre National Institute of Mental Health (NIMH – Institutul National de Sanatate Mentala) din SUA, care a lansat un atac usturator asupra DSM, criticandu-i “lipsa de validitate” si anuntand ca isi “reorienteaza cercetarile [finantarea] in afara categoriilor DSM” si in directia stabilirii unui nou sistem de clasificare, bazat atat pe biologie cat si pe simptomele tulburarilor mentale.
Proiectul Research Domain Criteria (RDoC), afirma de curand Thomas Insel, director al NIMH, a fost “numai un plan destinat transformarii practicii clinice, prin realizarea unor noi cercetari, pentru a obtine informatii privitoare la modul in care diagnosticam si tratam tulburarile mentale.”
Viitorul sanatatii mentale pe termen lung, a spus el, sta in depistarea biomarkerilor: “Spre deosebire de definitiile cardiopatiei ischemice, limfomului sau cele ce vizeaza SIDA, diagnosticele DSM se bazeaza pe un consens privind grupuri de simptome clinice, si nu pe vreo determinare obiectiva de laborator.”22
Inceput practic de la zero, RDoC este, deocamdata, o provocare prea indepartata ca sa dobandeasca suprematia fata de DSM. “Este calea de urmat, insa nicaieri nu este situata in proximitatea unui cadru propice aplicarii ei in vederea crearii unui sistem diagnostic,” afirma Shitij Kapur, decan al Institute of Psychiatry de la King’s College London si autor al unui articol, publicat anul trecut, ce examina motivele pentru care psihiatriei biologice i-a luat atat de mult timp ca sa ajunga la elaborarea testelor clinice.23
Deocamdata, spune el, “avem o munca de facut, iar [ICD si DSM] sunt instrumentele de care dispunem.” Diferentele dintre ele “sunt, in 95% din cazuri, fie lipsite de importanta, fie doar pentru cunoscatori,” iar in realitate se pune intrebarea “are lumea nevoie de un DSM si de o ICD?”
Kapur este de parere ca agitatia prilejuita de noul DSM “se va disipa complet, fiindca DSM-5 nu este o revolutie; abia daca este o imbunatatire sensibila. Exista oameni care sunt dezamagiti, deoarece in urma cu 10 ani se nutrea speranta ca vom detine teste clare biologice si ca noul DSM va revizui radical toate deficientele pe care le avem in tulburarile psihiatrice.”
El sustine ca nu este prea simplist sa caracterizam controversa legata de DSM drept psihiatrie versus psihoterapie ori medicatie versus terapie prin cuvant si ca acele tabere au “emanat” tensiunile pe fondul lansarii DSM.
“Asta nu inseamna ca tensiunile nu sunt reale sau importante, ci doar ca nu s-au nascut ieri, iar DSM-5 nu le face neaparat mai bune ori mai rele.”
 Influenta DSM in Marea Britanie
Pe 4 iunie, Institute of Psychiatry de la King’s College a gazduit o conferinta internationala de doua zile pe tema DSM-5 si “viitorul diagnosticului psihiatric.” Desi Marea Britanie utilizeaza ICD, Kapur sustine ca ar fi o greseala sa se presupuna ca DSM nu are niciun efect asupra psihiatriei britanice.
“Nu ar fi intelept pentru restul lumii sa ignore lucrurile ce se petrec in SUA pentru ca acolo este, fara niciun dubiu, centrul de putere academic si profesional in psihiatrie, acolo se genereaza atat de numeroase concepte, idei, descoperiri si de aproape 10 ori mai multe articole decat in orice alta tara”, mai spune el.
Cand vine vorba de discursul stiintific, adauga Kapur, DSM are un ”ascendent„ asupra ICD: un psihiatru britanic care trateaza un pacient cu schizofrenie va citi, cel mai probabil, articole tematice ai caror subiecti fusesera diagnosticati de catre medici utilizatori ai DSM.
Ca editor al British Journal of Psychiatry, Tyrer declara ca le reaminteste periodic autorilor americani “ca Marea Britanie este printre ultimele regiuni ale lumii unde nu exista DSM, fiindca nu am fost influentati de vanzarile importante ale DSM.”
Oricum, afirmatia ‘aceasta persoana are un diagnostic DSM de depresie majora’ are mai multa greutate decat daca s-ar spune ‘aceasta persoana are un diagnostic ICD de boala depresiva usoara.’”
Cele de mai sus au fost demonstrate printr-un important proces britanic din 2005, in care un barbat acuzat ca, dupa ce si-a ucis parintii, s-a distrat cheltuindu-le banii adunati pe cartile de credit a evitat o condamnare pentru crima prin admiterea omorului cu responsabilitate diminuata pe baza faptului ca avea o personalitate narcisista.24 Tulburarea apare numai in DSM: “Narcisismul nu a fost niciodata in clasificarea ICD si sunt sigur ca nu va fi,” afirma Tyrer. “Este un diagnostic de vanitate atat pentru pacienti cat si pentru doctorii lor.”
 Apararea DSM
Unul dintre participantii la conferinta referitoare la DSM-5 este David Kupfer, presedintele grupului de lucru pentru DSM-5; el are ferma convingere ca Marea Britanie merita o vizita imediat dupa publicarea manualului – intr-o perioada care, din punctul lui de vedere, va fi, cu siguranta, frenetica – si nu lasa catusi de putin impresia unui barbat care sta pe un scaun diabolic de fierbinte.
Unul dintre mesajele cheie pe care este dornic sa le transmita este ca DSM-5 ramane “cea mai buna stiinta disponibila [si] manualul cel mai util clinicienilor pentru asistenta pacientilor” – si, deloc surprinzator, nu accepta ideea ca DSM ar trebui sa cedeze locul ICD-ului.
“DSM si ICD pot fi considerate publicatii pereche,” afirma Kupfer. “Ele sunt corelate, astfel ca un clinician care foloseste DSM poate utiliza sistemul de codificare diagnostica ICD solicitat in majoritatea sistemelor de sanatate din lume. Este important de retinut ca ICD nu include criterii diagnostice descriptive, ci numai o lista de tulburari. DSM-5 este ghidul clinic cel mai bun posibil pentru diagnosticul tulburarilor mentale.”
La fel, in ciuda vehementei atacului NIMH la adresa DSM, el insista ca “DSM-5 si RDoC al National Institute reprezinta cadre de lucru complementare, nu competitive. Odata ce eforturile RDoC vor capata contur, orice informatie sau caracteristica rezultata din agenda sa de cercetare va fi integrata in editiile viitoare ale DSM, pentru a intari asistenta pacientilor.”
Kupfer a ocolit si raspunsul la intrebarea legata de dificultatea de a-l avea pe predecesorul sau ca presedinte al DSM-IV drept cel mai inversunat critic al DSM-5.
“Chiar daca este obligatoriu sa apara si critici,” a spus, “credem ca este important sa ramanem concentrati pe faptul ca DSM-5 a fost elaborat in decurs de peste un deceniu, beneficiind de concursul a cel putin 1 500 dintre cei mai buni experti in domeniu si de sinteze in extenso din literatura de specilitate, de cercetari originale si de trialuri la scara nationala.”
Bineinteles ca si acele trialuri au provocat, la randul lor, controverse. Pentru Farley si altii, ele au aratat doar faptul ca “stiinta [de la baza DSM-5] nu este suficient de buna.”
Intre noiembrie 2010 si noiembrie 2012, criteriile DSM-5 pentru 23 de tulburari au fost testate de sute de psihiatri care au lucrat cu 3 500 de pacienti la nivel national. Conform APA, sase diagnostice “au avut scoruri de incredere relativ scazute, fapt caracterizat in raport drept chestionabil, dar acceptabil”; printre ele erau doua dintre cele mai frecvente diagnostice din DSM: tulburarea depresiva majora si tulburarea de anxietate generalizata.
 Amenintarile legislative
In prezent, toate dezbaterile privitoare la ce anume ar trebui si ce nu ar trebui sa fie inclus in DSM-5 au loc la nivel academic. S-ar putea, insa, ca viitorul manualului sa fie amenintat pe termen mai lung in forma trecerii obligatorii, in octombrie 2014, de la seturile de coduri ICD-9 la cele ICD-10, pentru toti furnizorii de asistenta pentru sanatate vizati de US Health Insurance Portability and Accountability Act (HIPAA – Legea mobilitatii si responsabilitatii asigurarilor de sanatate din SUA), ce intra in programul national de asigurari Medicare si in Medicaid, programul de sanatate cu testarea mijloacelor financiare in vederea eligibilitatii.
Ca si in cazul ICD-9, SUA a modificat ICD-10 ca sa-l utilizeze in propriul sistem medical, dar deosebirea este ca, pentru prima data, ICD-10-CM va impinge multi psihiatri si psihologi in afara orbitei DSM.
“Actualmente, numerosi psihologi folosesc DSM-IV-TR cand diagnosticheaza pacientii si codurile corespunzatoare DSM-IV-TR pentru a depune o solicitare la asigurarea medicala,” a mentionat asociatia psihiatrica intr-o actualizare adresata membrilor sai in februarie. Acest lucru era in regula in cazul ICD-9, intrucat codurile sale diagnostice erau aliniate cu cele ale DSM, dar codurile ICD-10 vor fi diferite si “oricine va inregistra codurile DSM in loc de cele ale ICD-10-CM putem presupune ca risca sa se confrunte cu refuzul solicitarii de plata.”26
Este usor de criticat, spune Kapur, dar “cred ca multi oameni nu cunosc deloc istoria, fiindca pot gasi orice defect pentru DSM, dar nu stiu nimic despre confuzia ce domnea in privinta diagnosticarii tulburarilor psihiatrice in urma cu 40 de ani... Ce se numea schizofrenie in New York nu era schizofrenie in Londra, iar din acest punct de vedere am facut un salt urias.”

Jonathan Gornall jurnalist independent, Suffolk, Marea Britanie
jgornall@mac.com
Competing interests: Niciunul de declarat.
Provenance and peer review: Articol solicitat; fara evaluare externa.
Bibliografia se gaseste in versiunea de pe bmj.com
 Traducere: Dr. Rodica Chirculescu
sursa  :
http://www.bmj.ro/articles/2013/12/05/dsm-5-un-diagnostic-fatal